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http://www.archive.org/details/treatiseonscienc1885play 


A   TREATISE 


THE  SCIENCE  AND  PRACTICE 


MIDWIFEET. 


W.  S.  PLAYFAIR,M.D.,F.R.C.P., 

PHySICTAN-ACCOUCHEUR  TO  H.  I.  AND  R.  H.  THE  DUCHESS  OF  EDINBURGH  ;    PROFESSOR  OF  OBSTETRIC 
MEDICINE  IN   king's  COLDEGE  ;   PHYSICIAN  FOR  THE  DISEASES  OF  WOMEN   AND  CHILDREN  TO 
king's  COLLEGE  HOSPITAL;    CONSULTING    PHYSICIAN  TO  THE  GENERAL    LYING-IN  HOS- 
PITAL, AND    TO    THE    EVELINA    HOSPITAL    FOE    CHILDREN;     LATE     PRESIDENT 
OF    THE    OBSTETRICAL    SOCIETY    OF    LONDON  ;     EXAMINER    IN     MID- 
WIFERY   TO    THE    UNIVERSITY    OF    LONDON    AND    TO 
THE  ROYAL  COLLEGE  OF   PHYSICIANS. 


FOURTH  AMERICAN  FROM  THE  FIFTH  ENGLISH  EDITION. 

WITH   NOTES   AND   ADDITIONS 

BY 

ROBERT   P.  HARRIS,  M.D. 

WITH    THREE    PLATES   AND  TWO    HUNDRED   AND   ONE    ILLUSTRATIONS. 


PHILADELPHIA: 
LEA    BROTHERS    &    CO. 

IS  ST). 


.  <^ 


Entered  according  to  Act  of  Congress,  in  the  year  1885,  by 

LEA    BROTHERS    &    CO., 

in   the  Office  of  the  Librarian  of  Congress  at  Washington.     All  rights  reserved. 


Westcott  &  Thomson,  William  J.  Dornan, 

Stereolypers  and  Jilectrolypers,  Philada.  Printe.r.  P/iilada. 


DEDICATION. 


TO 


THOMAS  ADDIS  EMMET,  M.D.,  LL.D., 


AS   A    MARK    OF 


PERSONAL    ESTEEM, 


ADMIRATION  FOR  HIS  MANY  VALUABLE  CONTRIBUTIONS 
TO   MEDICAL  SCIENCE. 


31   GcoRGE  Street,  Hanover  Square, 
March,  1885. 


AMERICAN  PUBLISHER'S  NOTICE. 


The  Author  has  carefully  revised  this  edition  of  his  Treatise  on 
Obstetrics,  and  presented  the  subject  in  its  latest  aspect  from  a  British 
standpoint.  It  is  well  known,  however,  that  American  oj^inions  and 
practice  differ  somewhat  from  those  of  Great  Britain,  and  require  that 
certain  teachings  should  be  remodelled  in  accordance  with  our  usages 
and  experience.  We  differ  in  the  form  of  decubitus  for  the  application 
of  the  forceps ;  in  the  models  of  instruments  in  use ;  in  the  measure  of 
fear  of  the  Csesarean  operation  when  based  upon  our  more  favorable 
results;  on  the  question  of  the  use  of  stimulants  for  wet-nurses  and 
convalescent  parturient  women,  etc. 

During  the  several  months  that  have  elapsed  since  the  publication  of 
the  English  edition  large  additions  have  been  made  to  our  obstetrical 
statistics,  and  some  changes  effected  in  the  management  of  cases  requir- 
ing surgical  assistance.  The  American  Editor  feels  that  he  has  been 
called  upon  to  bring  up  his  work  to  the  latest  period,  and  has  therefore 
added  the  new  forms  of  Csesarean  operation  devised  in  Germany,  the 
experiences  in  Berlin  with  Hicks'  method  of  treating  placenta  prsevia, 
the  latest  American  statistics  in  the  Cesarean  section  and  laparo-elytro- 
tomy,  the  latest  Porro  statistics  of  the  world,  etc.  He  has  also  added 
articles  on  spondylolisthesis  (a  pregnant  case  of  which  is  now  in  this 
city),  the  rational  treatment  of  rupture  of  the  uterus,  etc.  In  all  cases 
the  additions  have  been  distinguished  by  enclosure  in  brackets  [ — ]. 

Philadelphia,  March,  1S85. 


AUTHOR'S  PREFACE 


FOUETH  AMEEIOAN   EDITIOE^ 


In  preparing  a  new  edition  of  his  work  on  Midwifery  for  his  Ameri- 
can readers,  the  Anthor  has  gratefully  to  acknowledge  the  kind  reception 
it  continues  to  receive  from  the  profession,  A  comjaaratively  short  time 
having  elapsed  since  the  last  edition  was  jxiblished,  there  are  naturally 
not  many  changes  to  make.  The  whole  work,  however,  has  been  care- 
fully revised,  and  the  chapter  on  "  Conception  and  Generation  "  has  been 
in  great  part  rewritten,  so  as  to  incorporate  the  most  recent  advances  in 
Embryology.  The  Author  has  to  acknowledge  the  kind  assistance  he 
has  received  in  this  subject  from  his  late  colleague,  Dr,  W.  Tyeeell, 
Brookes,  formerly  of  the  Physiological  Laboratory  in  King's  College, 
now  of  Oxford,  Several  new  illustrations  have  been  added,  and  it  is 
lioped  that  the  work  may  thus  prove  more  worthy  of  being  used  as  a 
guide  in  the  anxieties  and  emergencies  of  obstetric  practice. 

."]  George  Street,  Hanover  Square,  W.,  London, 
August,  ISS4. 


PREFACE  TO  THE  FIRST  EDITIOiN. 


Those  who  have  studied  the  progress  of  Midwifery  know  that  there 
is  no  department  of  medicine  in  ^hieh  more  has  been  done  of  late  years, 
and  none  in  which  modern  views  of  practice  diifer  more  widely  from 
those  prevalent  only  a  short  time  ago.  The  Author's  object  has  been  to 
place  in  the  hands  of  his  readers  an  epitome  of  the  science  and  practice 
of  midwifery  which  embodies  all  recent  advances.  He  is  aware  that  on 
certain  important  points  he  has  recommended  practice  which  not  long 
ago  would  have  been  considered  heterodox  in  the  extreme,  and  which 
even  now  will  not  meet  with  general  approval.  He  has,  however,  the 
satisfaction  of  knowing  that  he  has  only  done  so  after  very  deliberate 
reflection,  and  Avith  the  profound  conviction  that  such  changes  are  right 
and  that  they  will  stand  the  test  of  experience.  He  has  endeavored  to 
dwell  especially  on  the  practical  part  of  the  subject,  so  as  to  make  the 
work  a  useful  guide  in  this  most  anxious  and  responsible  branch  of  the 
profession.  It  is  admitted  by  all  that  emergencies  and  difficulties  arise 
more  often  in  this  than  in  any  other  branch  of  practice ;  and  there  is  no 
part  of  the  practitioner's  work  which  requires  more  thorough  knowledge 
or  greater  experience.  It  is,  moreover,  a  lamentable  fact  that  students 
generally  leave  their  schools  more  ignorant  of  obstetrics  than  of  any 
other  subject.  So  long  as  the  absurd  regulations  exist  which  oblige  the 
lecturer  on  midwifery  to  attem])t  tlie  impossible  task  of  teaching  obstet- 
rics in  a  short  three  months'  coui'sc — an  absurdity  which  has  over  and 
(A'cr  again  been  pointed  out — such  must  of  necessity  be  the  case.  This 
nnist  be  the  Author's  excuse  for  dwelling  on  many  topics  at  greater 
l(!ngth  than  some  will  doubtl(!ss  think  their  im|)ortancc  merits,  since  he 
desires  to  ))lace  in  the  hands  of  his  students  a  work  which  may  in  sonu; 
measure  su|)ply  tiu'  inevitable  defects  of  liis  lectures. 


viii  PREFACE  TO   THE  FIRST  EDmON. 

Many  of  tlio  illustrations  are  copied  from  previous  authors,  while 
some  are  original.  The  followint)-  quotation  from  the  preface  to  Tyler 
Smith's  Jlaiiual  of  Obdetrioi  will  explain  why  the  source  of  the  copied 
wood-cuts  has  not  been  in  each  instance  acknowledged  :  "  When  I  began 
to  publish,  I  determined  to  give  the  authority  for  every  wood-cut  copied 
from  other  works.  I  soon  found,  however,  that  obstetric  authors  of  all 
countries,  from  the  time  of  Mauri ceau  downward,  had  copied  each  other 
so  freely  without  acknowledgment  as  to  render  it  difficult  or  imjjossible 
to  trace  the  originals." 

The  Author  has  to  express  his  acknowledgments  to  many  friends  for 
their  kind  assistance  by  the  loan  of  illustrations  and  otherwise,  and  more 
especially  to  his  colleague,  Dr.  Hayes,  for  his  valuable  aid  in  passing 
the  work  through  the  press. 

31  George  Street,  Hanover  Square, 
March,  187G. 


CONTENTS. 


PART   I. 

AXATOMY  AND   PHYSIOLOGY  OF  THE   ORGANS   CONCERNED 
IN  PARTURITION. 


CHAPTER   I. 

ANATOMY    OF   THE   PELVIS. 

PAGE 

Its  importance — Formation  of  the  Pelvis — Tlie  os  innominatum  :  its  three  divis- 
ions— Separation  between  tlie  True  and  False  Pelvis — The  Sacrum  and  Coc- 
cyx-— Mechanical  relations  of  the  Sacrum — Pelvic  articulations  and  ligaments 
— Movements  of  the  Pelvic  Joints — The  Pelvis  as  a  whole — Differences  in  the 
Two  Sexes — Measurements  of  the  Pelvis — Its  diameters,  planes,  and  axes- 
Development  of  the  Pelvis — Soft  parts  in  connection  with  the  Pelvis    ...     33 


CHAPTER   II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  Function :  ] .  External  or  Copulative  ;  2.  Internal  or  Forma- 
tive Organs — Mons  Veneris — Labia  niajora  and  minora — The  Clitoris — The 
\'estibule  and  Orifice  of  Urethra — Passing  of  the  female  catheter — Oritice  of 
Vagina— The  Hymen  — The  glands  of  the  Vulva  — The  Perineum— The  Vagina 
— The  Uterus:  its  position  and  anatomy — The  Ligaments  of  the  Uterus — The 
Parovarium — The  Fallopian  Tubes— The  Ovaries— The  Graafian  Follicles  and 
the  Ova — The  Mammary  Glands 49 

CHAPTER   IIL 

OVULATION    AND   MENSTRUATION. 

Functions  of  the  Ovary — Changes  in  tiie  Graafian  Follicle:  1.  Maturation;  2. 
Escape  of  the  Ovum — Formation  of  the  Corpus  Luteum — Quality  and  source 
of  the  Menstrual  Idood — Tiieory  of  Menstruation — I'ur))ose  of  the  Menstrual 
loss — Vicarious  Men.striiation — Ce.ssation  of  Menstruation SI 


PART  n. 

PR  E  G  NA  X  C  Y 


CHAPTER  I. 

CONCEPTION    AND   (;ENi:riATION. 

PAtiE 

The  .Semen^Site  and  mode  of  Impregnation — Changes  in  the  Ovum — Cleavage 
of  tlie  Yelk — The  Decidua  and  its  formation — Formation  of  the  Amnion — The 
Umbilical  Vesicle  and  Allantois— Tiie  Liqiior  Amnii  and  its  uses — Tlie  Cho- 
rion— The  Placenta:   its  formation,  anatomy,  and  finictions 95 


CHAPTER   II. 

THE    ANATOMY   AND   PHYSIOLOCiY    OF   THE    FCETUS. 

Appearance  of  the  Fcetus  at  various  stages  of  development — Anatomy  of  the  Fatal 
Head — The  Sutures  and  Fontanelles — Influence  of  Sex  and  Race  on  the  Fa- 
tal Head — Position  of  the  Fcetus  in  utero — Functions  of  the  Fcetus — The  Foetal 
Circulation 118 

CHAPTER   III. 

PREGNANCY. 

Changes  in  the  form  and  dimensions  of  the  Uterus — Changes  in  the  Cervix — 
Changes  in  the  texture  of  the  Uterine  Tissues,  the  Peritoneal,  Muscular,  and 
Mucous  Coats — General  modifications  in  the  Body  produced  by  Pregnancy    .   1 32 

CHAPTER  IV. 

SIGNS   AND   SYMPTOMS   OF   PREGNANCY. 

Signs  of  a  fruitful  Conception— Cessation  of  Menstruation— Synipnthetic  Disturb- 
ances: Morning  Sickness,  etc.— Mammary  Changes— Enlargement  of  the  Ab- 
domen—Quickening — Intermittent  Uterine  Ccnitractions— Vaginal  Signs  of 
Pregnancy— Ballottement,  etc. — Auscultatory  Signs  of  Pregnancy— Foetal  Pul- 
sations— Uterine  Souffle,  etc 143 

CHAPTER  V. 

THE     DIFFERENTI.'VL      DIACiNOSIS      OF      PREGNANCY— SPITRIOUS     PREGNANCY— THE 
DURATION  OF   PREGNANCY— SIGNS   OF   RECENT   PREGNANCY. 

.Ulipose  enlargement  of  the  Abdomen— Distension  of  the  Uterus  by  retained 
Menses,  etc.— Congestive  enlargement  of  the  Uterus — Ascites — Uterine  and 
Ovarian  Tumors — Spurious  Pregnancy:  its  Causes,  Symptoms,  and  Diagnosis 
— The  Duration  of  Pregnancy— Sources  of  Fallacy— Methods  of  Predicting 
Date  of  Delivery — Protraction  of  Pregnancy— Signs  of  recent  Delivery     .    .   157 


CONTENTS.  xi 

CHAPTER  VI. 

ABHrOEMAL     PREGNANCY,    INCLUDING     MULTIPLE     PREGNANCY,    SUPER-FCETATION, 
EXTRA-UTERINE   FCETATION,   AND  MISSED   LABOR. 

PAGE 

Plural  Births,  their  frequency :  Relative  frequency  in  different  Countries ; 
Causes,  etc. — Super-foetation  and  Supei'-fecundation — Nature — Explanation — 
Objections  to  admission  of  such  cases — Their  possibility  admitted — Extra- 
uterine Pregnancy — Classification — Causes — Tubal  Pregnancies — Changes  in 
the  Fallopian  Tubes — Condition  of  Uterus — Progress  and  Termination — Diag- 
nosis— Treatment — Abdominal  Pregnancy  :  Description  ;  Diagnosis  ;  Treat- 
ment— Missed  Labor :    its  Symptoms,  Causes,  and  Treatment 166 


CHAPTER  VII. 

DISEASES    OF   PREGNANCY. 

Some  only  Sympathetic,  othefs  Mechanical  or  Complex  in  their  Origin — Derange- 
ments of  the  Digestive  Organs :  Excessive  Nausea  and  Vomiting ;  Diarrhoea ; 
Constipation  ;  Hemorrhoids ;  Ptyalism  ;  Dyspnoea,  etc. — Palpitation — Syncope 
— Anaemia  and  Chlorosis — Albuminuria 198 


CHAPTER  VIII. 

DISEASES    OF   PREGNANCY   {continued). 

Disorders  of  the  Nervous  System :  Insomnia ;  Headaches  and  Neuralgia ;  Par- 
alysis ;  Chorea ;  Disorders  of  the  Urinary  Organs  ;  Retention  of  Urine ;  Irri- 
tability of  the  Bladder  ;  Incontinence  of  Urine;  Phosphatic  Deposits  ;  Leucor- 
rhoea ;  Effects  of  Pressure ;  Laceration  of  Veins ;  Displacements  of  the  Gravid 
Uterus ;  Prolapse,  Anteversion,  Retroversion — Diseases  co-existing  with  Preg- 
nancy: Eruptive  Fevers — Small-pox,  Measles,  Scarlet  Fever,  Continued  Fever; 
Phthisis;  Cardiac  Disease ;  Syphilis;  Icterus;  Carcinom.a;  Pregnancy  compli- 
cated with  Ovarian  and  Fibroid  Tumors 211 


CHAPTER  IX. 

PATHOLOGY   OF  THE  DECIDUA  AND   OVUM. 

Pathology  of  the  Decidua — Hydrorrhoea  Gravidarum — Pathology  of  the  Chorion  ; 
Vesicular  Degeneration,  Myxoma  Fibrosum — Pathology  of  the  Placenta ;  Blood 
Extravasations,  Fatty  Degeneration,  etc. — Pathology  of  the  Umbilical  Cord — 
Pathology  of  the  Amnion,  Ilydramnios;  Deficiency  of  Liquor  Anmii,  etc. — 
Pathology  of  the  Ffjetus  :  Blood  Diseases  transmitted  through  the  Mother, 
Small-pox,  Measles,  and  Scarlet  Fever,  Intermittent  Fevers,  Lead-poisoning, 
Syphilis — Imflammatory  Disea.ses— Dropsies — Tumors — Wounds  and  Injuries 

of  the  Fcjetus — Intra-uterine  Amputations — Deatli  of  the  Foetus 226 

2 


xii  CONTENTS. 

CHAPTER  X. 

ABORTION  AND   PREMATURE   LABOR. 

PAGE 

Imioortance  and  Frequency — Definition  and  Classification — Frequency — Recur- 
rence—Causes— Causes  referable  to  Foetus — Changes  in  a  Dead  Ovum  retained 
in  Utero — Extravasations  of  Blood — Moles,  etc. — Causes  depending  on  Mater- 
nal State — Syphilis :  Causes  acting  through  Nervous  System,  Physical  Causes, 
etc. — Causes  depending  on  Moi-bid  States  of  Uterus — Symptoms — Preventive 
Treatment— Prophylactic  Treatment — Treatment  when  Abortion  is  inevitable 
— After-treatment 242 


PART   III. 

LABOR. 


CHAPTER   I. 

THE  PHENOMENA  OF  LABOR. 

Causes  of  Labor — Mode  in  which  the  Expulsion  of  the  Child  is  efTected — The 
Uterine  Contraction — Mode  in  which  the  Dilatation  of  the  Cervix  is  eflfected — 
Rupture  of  the  Membranes — Character  and  Source  of  Pains  during  Labor — 
Effect  of  Pains  on  Mother  and  Fojtus — Division  of  Labor  into  Stages— Pre- 
paratory Stage — False  Pains  — First  Stage — Second  Stage — Third  Stage — Mode 
in  which  the  Placenta  is  expelled — Duration  of  Labor 255 


CHAPTER   IL 

MECHANISM   OF  DELIVERY   IN   IIE.AD   PRESENTATIONS. 

Importance  of  Subject — Frequency  of  Head  Presentations — The  Difierent  Posi- 
tions of  the  Head — First  Position — Division  of  Mechanical  Movements  into 
Stages — Flexion — Descent  and  Levelling  Movement — Rotation — Extension — 
External  Rotation — Second  Position — Third  Position — Fourth  Position — Caput 
Succedaneum — Alteration  in  Shape  of  Head  from  Moulding 2G8 

CHAPTER  III. 

MANAGEMENT  OF  NATURAL  LABOR. 

Preparatory  Treatment — Dress  of  Patient  during  Pregnancy — Tlie  Obstetric  Bag — 
Duties  on  first  visiting  Patient — False  Pains — Their  Character  and  Treatment 
— Vaginal  Examination — The  Position  of  Patient — Artificial  Rupture  of  Mem- 
branes— Treatment  of  Propulsive  Stage — Relaxation  of  the  Perineum — Treat- 
ment of  Lacerations — Expulsion  of  Child — Promotion  of  Uterine  Contraction — 
Ligature  of  the  Coi-d — Management  of  the  Third  Stage  of  Labor — Application 
of  the  Binder — After-treatment 280 


CONTENTS.  xiil 

CHAPTER  IV. 

ANAESTHESIA  IN   LABOE. 

PAGE 

Agents  employed — Chloral:    its  Object   and  Mode  of  Administration — Ether — 
Chloroform :   its  Use,  Objections  to,  and  Mode  of  Administration 295 


CHAPTER  V. 

PELVIC   PRESENTATIONS. 

Frequency — Causes — Prognosis  to  Mother  and  Child — Diagnosis  by  Abdominal 
Palpation  and  by  Vaginal  Examination — Difierential  Diagnosis  of  Breech, 
Knee,  and  Feet — Mechanism — Treatment — Management  of  Impacted  Breech 
Presentations 299 


CHAPTER  VI. 

PRESENTATIONS   OF  THE   FACE. 

Erroneous  Views  formerly  held  on  the  Subject — Frequency — Mode  of  Production 
— Diagnosis — Mechanism — Four  Positions  of  the  Face — Description  of  Deliv- 
ery in  First  Face  Position — Mento-posterior  Position  in  which  Rotation  does 
not  take  place — Prognosis — Treatment — Brow  Presentations 310 


CHAPTER  VII. 

DIFFICULT  OCCIPITO-POSTERIOR   POSITIONS. 

Causes  of  Face  to  Pubes  Delivery — Mode  of  Treatment — Upward  Pressure  on 
Forehead — Downward  Traction  on  Occiput — Use  of  Forceps — Peculiarities  of 
Forceps  Delivery 319 


CHAPTER  VIII. 

PRESENTATIONS   OF   SHOULDER,   ARM,   OR   TRUNK— COMPLEX   PRESENTATIONS— PRO- 
LAPSE OF  THE  FUNIS. 

Position  of  the  Foetus — Division  into  Dorso-anterior  and  Dorso-posterior  Positions 
— Causes — Prognosis  and  Frecpiency — Diagnosis — Mode  of  distinguishing  Po- , 
sition  of  Child — Differential  Diagnosis  of  vSlioulder,  Elbow,  and  Hand — Mech- 
anism— Tlie  Two  Possible  Modes  of  Delivery  by  the  Natural  Powers — Spon- 
taneous Version — Spontaneous  JOv(»hition — Treatment — Complex  Presentation : 
Foot  or  Hand,  with  Head,  Hand,  and  Feet  together — Dorsal  Displacement  of 
the  Arm — Prolapse  of  the  Umbilical  Cord — Frequency — Prognosis— Causes — 
Diagnosis — Postural  Treatment — Artificial  Reposition — Treatment  when  Re- 
position fails 322 


XIV  CONTENTS. 

CHAPTER  IX. 

PROLONGED   AND   PEEC'IPITATE   LABORS. 

I'AGK 

Evil  Effects  of  Prolonged  Labor — Influence  of  tlie  Stage  of  Labor  in  Protraction — 
Delay  in  the  First  Stage  rarely  serious — Teniporai'y  Cessation  of  Pains — Symp- 
toms of  Protraction  in  the  Second  Stage — State  of  the  Uterus  in  Protracted 
Labor — Cases  of  Protraction  due  to  morbid  condition  of  the  expulsive  powers — 
Causes  of  Protraction — Treatment — Oxytocic  Remedies — Ergot  of  Rye,  etc. — 
Manual  Pressure— Instrumental  Delivery  (case  of  Princess  Charlotte  of  Wales) 
— Precipitate  Labor — Its  Causes  and  Treatment 337 


CHAPTER   X. 

LABOR  OBSTRUCTED  BY  FAULTY  CONDITION  OF  THE  SOFT  PARTS. 

Rigidity  of  the  Cervix :  its  Causes,  Effects,  and  Treatment — Ante-partnm  Hour- 
glass Contraction — Bands  and  Cicatrices  in  the  Vagina — Extreme  Rigidity  of 
the  Perineum — Labor  complicated  with  Tumor — Vaginal  Cystocele — Calculus 
— Hernial  Protrusions — CEdema  of  Vulva — Haematic  Effusions,  etc 351 

CHAPTER  XL 

DIFFICULT  LABOR  DEPENDING  ON  SOME  UNUSUAL  CONDITION  OF  THE  FCETUS. 

Plural  Births,  Treatment  of — Locked  Twins — Conjoined  Twins — Intra-uterine 
Hydrocephalus :  its  Dangers,  Diagnosis,  and  Treatment — Other  Dropsical 
Effusions — Foetal  Tumors — Excessive  Development  of  Foetus 363 

CHAPTER  XII. 

DEFORMITIES   OF  THE   PELVIS. 

Classification — Causes  of  Pelvic  Deformity — Rickets  and  Osteo-malacia — The 
Equally-enlarged  Pelvis — The  Equally-contracted  Pelvis — The  L'ndeveloped 
Pelvis — Masculine  or  Funnel-shaped  Pelvis — Contraction  of  Conjugate  Diam- 
eter of  tlie  Brim — Figure-of-eight  Deformity — Spondylolisthesis — Sjjondylo- 
lizema — Narrowing  of  the  Oblique  Diameters — Obliquely-contracted  Pelvis — 
Kyphotic  Pelvis — Robert's  Pelvis — Deformity  from  Old-standing  Hip-joint 
Disease — Deformity  from  Tumors,  Fractures,  etc. — Effects  of  Contracted  Pelvis 
on  Labor — Risks  to  the  Mother  and  Child — Mechanism  of  Delivery  in  Head 
Presentation  :  a,  in  Contracted  Brim  ;  6,  in  Generally-contracted  Pelvis — Diag- 
nosis— External  Measurements — Internal  Measurements — Mode  of  Estimating 
the  Conjugate  Diameter  of  the  Brim — Mode  of  Diagnosing  the  Oblique  Pelvis 
— Treatment — The  Forceps — Turning — Craniotomy — The  Induction  of  Pre- 
mature Labor — Induction  of  Abortion 375 

CHAPTER   XIII. 

HEMORRHAGE  BEFORE  DELIVERY :    PLACENTA*  PRJEVIA. 

Definition — Causes — Symptoms — Sources  and  Causes  of  Hemorrhage — Prognosis — 
Treatment 400 


CONTENTS.  XV 

CHAPTER  XIV. 

HEMORRHAGE  FROM  SEPARATION   OF  A  NORMALLY-SITUATED   PLACENTA. 

PAGE 

Causes  and  Pathology — Symptoms  and  Diagnosis — Prognosis — Treatment  ....   411 

CHAPTER  XV. 

HEMORRHAGE  AFTER  DELIVERY. 

Its  Frequency — Generally  a  Preventible  Accident — Causes — Nature's  Method  of 
controlling  Hemorrhages  —  Uterine  Contraction  —  Thrombosis —  Secondary 
Causes  of  Hemorrhage — Irregular  Uterine  Contraction — Placental  Adhesions 
— Constitutional  Predisposition  to  Flooding — Symptoms — Preventive  Treat- 
ment— Curative  Treatment — Secondary  I'reatment — Secondary  Post-partum 
Hemorrhage — Its  Causes  and  Treatment 415 

CHAPTER   XVI. 

RUPTURE  OF  THE   UTERUS,  ETC. 

Its  Fatality — Seat  of  Rupture — Causes,  Predisposing  and  Exciting — Symptoms — 
Prognosis — Treatment :  when  the  Foetus  remains  in  Utero ;  when  the  Foetus 
has  escaped  from  the  Uterus — Lacerations  of  the  Cervix — Recapitulation — 
Lacerations  of  the  Vagina — Vesico-  and  Recto-vaginal  Fistulse — Their  Mode 
of  Formation — Treatment 431 

CHAPTER   XVII. 

INVERSION  OF  THE   UTERUS. 

Division  into  Acute  and  Chronic  Forms— Description — Symptoms — Diagnosis — 
Mode  of  Production — Treatment 442 


PART  IV. 

OBSTETRIC   OPERATIONS. 


CHAPTER  I. 

INDUCTION   OF   PREMATURE   L.\ROR. 

History — Objects — May  be  performed  either  on  account  of  the  Mother  or  Child — 
Modes  of  inducing  Labor — Pimcture  of  Membranes — Administration  of  Oxy- 
tocics— Means  acting  Indirectly  on  the  Uterus — Dilatation  of  ('ervix — Separa- 
tion of  Membranes — Vaginal  and  Uterine  Douches — Introduction  of  Flexible 
(Jatheter 449 


XVL  '  CONTENTS. 

CHAPTER   II. 

TURNING. 

PAGE 

History— Turning  by  External  Manipulation— Object  and  Nature  of  the  Opera- 
tion—Cases Suitable  for  the  Operation — Statistics  and  Dangers — Method  of 
Performance— Cephalic  Version— Method  of  Performance — Podalic  Version — 
Position  of  Patient— Administration  of  Anaesthetics— Period  when  the  Opera- 
tion should  be  Undertaken — Choice  of  Hand  to  be  used — Turning  by  Bi-polar 
Method — Turning  when  the  Hand  is  introduced  into  the  Uterus — Turning 
in  Abdomino-anterior  Positions— Difficult  Cases  of  Arm  Presentation     .    .    .   457 


CHAPTEE   III. 

THE   FORCEPS. 

Frequent  Use  of  the  Forceps  in  Modern  Practice — Description  of  the  Instrument 
— The  Short  Forceps— Its  Varieties — The  Long  Forceps— Suitable  to  all  Cases 
alike — Action  of  the  Instrument — Its  Power  as  a  Tractor,  Lever,  and  Compress- 
or— Preliminary  Considerations  before  Operation — Use  of  Anaesthetics— De- 
scription of  the  Operation— Low  Forceps  Operation — High  Forceps  Operation 
— Possible  Dangers  of  Forceps  Delivery— Possible  Risks  to  the  Child    ....  472 


CHAPTER   IV. 

THE  VECTIS— THE   FILLET. 

Nature  of  the  Vectis — Its  Use  as  a  Lever  or  Tractor — Cases  in  which  it  is  Applica- 
ble— Its  Use  as  a  Rectifier  of  Malpositions — The  Fillet — Nature  of  the  Instru- 
ment— Objection  to  its  Use 495 


CHAPTER  V. 

OPERATIONS  INVOLVING   DESTRUCTION   OF  THE   FOETUS. 

Their  Antiqnity  and  Hist&ry — Division  of  Subject — Nature  of  Instruments  em- 
ployed— Perforator — Crotchet — Craniotomy  Forceps— Cephalotribe — Forceps- 
saw — Ecraseur — Basilyst — Cases  requiring  Craniotomy— Method  of  Perforation 
— Extraction  of  the  Head— Comparative  merits  of  Cephalotripsy  and  Cranioto- 
my— Extraction  by  the  Craniotomy  Forceps — Extraction  of  the  Body — Em- 
bryotomy— Decapitation  and  Evisceration 497 


CHAPTER   VI. 

THE  C^.SAREAN  SECTION— PORRO'S   OPERATION— SYJIPHYSEOTOMY. 

History  of  the  Operation — Statistics— Results  to  IMotlier  and  Child — Causes  requir- 
ing the  Operation — Post-mortem  Caesarean  Section — Causes  of  Death  after  the 
Caesarean  Section — Preliminary  Preparation — Description  of  the  Operation — 
New  Forms  of  Operating — Subsequent  Management — Porro's  Operation — Sub- 
stitutes for  the  Caesarean  Section — Symphyseotomy oil 


CONTENTS.  xvii 

CHAPTER  VII. 

LAPARO-ELYTROTOMY. 

PAGE 

History — Nature  of  the  Operation — Advantages  over  the  Caesarean  Section — Cases 
suitable  for  the  Ojoeration — Anatomy  of  the  Parts  concerned  in  the  Operation — 
Method  of  Performance — Subsequent  Treatment 529 

CHAPTER  VIII. 

THE  TRANSFUSION   OF  BLOOD. 

History — Nature  and  Object  of  the  Operation — Use  of  Blood  taken  from  the  Lower 
Animals — Difficulties  from  Coagulation  of  Fibrin — Modes  of  Obviating  them 
— Immediate  Transfusion — Addition  of  Chemical  Agents  to  prevent  Coagula- 
tion— Defibrination  of  the  Blood — Statistical  Results— Possible  Dangers  of  the 
Operation — Cases  suitable  for  Transfusion — Description  of  the  Operation — 
Schafer's  Directions  for  Immediate  Transfusion — Effects  of  Successful  Trans- 
fusion— Secondary  Effects  of  Transfusion 534 


PAET    Y. 

THE  PUERPERAL   STATE. 


CHAPTER  I. 

THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT. 

Importance  of  Studying  the  Puerperal  State — The  Mortality  of  Childbirth — 
Alterations  in  the  Blood  after  Delivery — Condition  after  Delivery — Nervous 
Shock — Fall  of  the  Pulse — The  Secretions  and  Excretions — Secretion  of  Milk 
— Changes  in  the  Uterus  after  Delivery — The  Lochia — The  After-pains — Man- 
agement of  Women  after  Delivery — Treatment  of  Severe  After-pains — Diet 
and  Regimen ....   546 


CHAPTER   11. 

MANAGEMENT  OF  THE  INFANT,   LACTATION,   ETC. 

Commencement  of  Respiration  after  the  Birth  of  the  Child — Apparent  Death  of 
the  New-born  Child — Its  Treatment — Wasliing  and  Dressing  the  Child— Ap- 
plication of  the  Child  to  the  Breast — The  Colostrum  and  its  Properties — Secre- 
tion of  Milk — Importance  of  Nursing — Selection  of  a  Wet-nurse — Manage- 
ment of  Lactation — Diet  and  Regimen  of  Nursing  Women — Period  of  Weaning 
— Disorders  of  Lactation — Means  of  Arresting  the  Secretion  of  Milk — Defective 
Secretion  of  Milk — Dejiressed  Nipples — Fissuics  and  Excoriations  of  tlie  Nip- 
ple's—Excessive I'Mow  of  Milk — Mammary  Abscess — Hand-feeding — Causes  of 
Mortality  in  Iland-feoding— Various  Kinds  of  Milk — Method  of  Hand-feeding  557 


XVI 11  CONTENTS. 

CHAPTER   III. 

PUERPERAL   ECLAMPSIA. 

PAGE 

Its  Doubtful  Etiology — Premonitory  Symptoms — Symptoms  of  the  Attack — Con- 
dition between  tlie  Attacks — Relation  of  the  Attacks  to  Labor — Results  to 
Mother  and  Child — Pathology— Treatment — Obstetric  Management     ....   573 


CHAPTER   IV. 

PUERPERAL   INSANITY. 

Classification — Proportion  of  Various  Forms — Insanity  of  Pregnancy — Predispos- 
ing Causes — Period  of  Pregnancy  at  which  it  Occurs — Type  of  Insanity — Prog- 
nosis— Transient  Mania  during  Delivery — Puerperal  Insanity  (Proper) — Type 
of  Insanity — Causes — Theory  of  its  Dependence  on  a  Morbid  State  of  the  Blood 
— Objections  to  the  Theory — Prognosis — Post-mortem  Signs — Duration — In- 
sanity of  Lactation — Type — Symptoms — Of  Mania — Of  Melancholia — Treat- 
ment— Question  of  Removal  to  Asylum — Treatment  during  Convalescence    .   582 

CHAPTER   V. 

PUERPERAL   SEPTrC.i<:MIA. 

DifTerences  of  Opinion — Confusion  from  this  Cause — Modern  View  of  this  Dis- 
ease— History — Its  Mortality  in  Lying-in  Hospitals — Numerous  Theories  as  to 
its  Nature — Theory  of  Local  Origin — Theory  of  an  Essential  Zymotic  Fever — 
Theory  of  its  Identity  with  Surgical  Septicaemia — Nature  of  this  View — Chan- 
nels through  which  Septic  Matter  may  be  Absorbed — Character  and  Origin  of 
Septie  Matter  often  Obscure — Division  into  Auto-genetic  and  Hetero-genetic 
Cases — Sources  of  Self-infection — Sources  of  Hetero-genetic  Infection — Influ- 
ence of  Cadaveric  Poison — Infection  from  Erysipelas — Infection  from  other 
Zymotic  Diseases — Infection  from  Sewer  Gas — Contagion  from  other  Puerperal 
Patients — Mode  in  which  the  Poison  may  be  Conveyed  to  the  Patient — Con- 
duct of  the  Practitioner  in  relation  to  the  Disease — Nature  of  the  Septic  Poison 
— Local  Changes  resulting  from  the  Absorption  of  Septic  Material — Channels 
through  which  Systemic  Infection  is  Produced — Pathological  Phenomena  ob- 
served after  General  Blond- Infection — Four  Principal  Types  of  Pathological 
Change — Intense  Cases  without  Marked  Post-mortem  Signs — Cases  character- 
ized by  Inflammation  of  the  Serous  Membranes — Cases  characterized  by  the 
Impaction  of  Infected  Emboli  and  Secondary  Inflammation  and  Abscess — 
Description  of  the  Disease — Duration — Varieties  of  Symptoms  in  Difl'erent 
Cases — Symptoms  of  Local  Complications — Treatment 593 

CHAPTER   VI. 

PUERPERAL   VENOUS   THROMBOSIS   AND    EMBOLISM. 

Puerperal  Thrombosis  and  its  Results — Conditions  which  favor  Thrombosis — Con- 
ditions which  fiivor  Coagulation  in  the  Puerperal  State — Distinction  between 
Thrombosis  and  Embolism — Is  Primary  Thrombosis  of  the  Pulmonary  Arte- 
ries possible? — History — Symptoms  of  Pulmonary  Obstruction — Is  Recovery 
possible — Causes  of  Death — Post-mortem  Appearances — Treatment — Puerperal 
Pleuro-pneumonia:  its  Causes  and  Treatment 621 


CONTENTS.  xix 

CHAPTER  VII. 

PUERPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM. 

PAGE 

Causes — Symptoms— Treatment 63S 

CHAPTER  VIII. 

OTHER  CAUSES   OF   SUDDEN    DEATH   DURING  LABOR  AND   THE   PUERPERAL    STATE- 

Organic  and  Functional  Causes — Idiopathic  Asphyxia — Pulmonary  Apoplexy — 
Cerebral  Apoplexy — Syncope — Shock  and  Exhaustion — Entrance  of  Air  into 
the  Veins 635- 

CHAPTER  IX. 

PERIPHERAL  VENOUS    THROMBOSIS   (SYNS.:     CRURAL    PHLEBITIS;    PHLEGMASIA    DO- 
LENS;    ANASARCA  SEROSA;    CEDEMA  LACTEUM ;    MILK  LEG,  ETC.). 

Nature — Symptoms — History  and  Pathology — Anatomical  Form  of  the  Thrombi 
in  the  Veins — Detachment  of  Emboli — Treatment 637 

CHAPTER  X. 

PELVIC  CELLULITIS   AND  PELVIC  PERITONITIS. 

Two  Forms  of  Disease — Variety  of  Nomenclature — Importance  of  Differential 
Diagnosis — Etiology — Connection  with  Septicaemia — Seat  of  Inflammation — 
Relative  Frequency  of  the  Two  Forms  of  Disease — Symptomatology — Results 
of  Physical  Examination — Terminations — Prognosis — Treatment 644 

INDEX 65a 


ILLUSTRATIONS. 


Plate  I. — Section  of  a  Frozen  Body  in  the  last  months  of  Pregnancy  (after 
Braune).  Ilhistrating  the  Relations  of  the  Uterus  to  the  surrounding  Parts, 
and  the  attitude  of  the  Foetus,  which  is  lying  in  the  second  Cranial  Posi- 
tion   Frontispiece 

Plate  II. — Section  of  a  Frozen  Body  at  the  termination  of  the  First  Stage  of 
Labor  (after  Braune).  Membranes  unbroken  ;  Cervix  fully  dilated  ;  and  the 
Head  (in  the  Second  Position)  in  the  Pelvic  Cavity Frontispiece 

Plate  III. — Illustrations  of  the  Corpora  Lutea  of  Menstruation  and  Pregnancy 

(after  Dalton) Facing  page  81 

FIU.  PAGE 

1.  Os  Innorainatum 34 

2.  Sacrum  and  Coccyx 35 

3.  Section  of  Pelvis  and  Heads  of  Thigh-bones,  showing  the  Susj^ensory  Action 

of  the  Sacro-iliac  Ligaments.     (After  Wood.) 37 

4.  Outlet  of  Pelvis 39 

5.  The  Female  Pelvis 40 

6.  The  Male  Pelvis 40 

7.  Brim  of  Pelvis,  showing  Antero-posterior,  Oblique,  and  Conjugate  Diameters  .  41 

8.  Transverse  Section  of  Pelvis,  showing  the  Diameters 42 

9.  Planes  of  the  Pelvis,  with  Horizon 43 

10.  Axes  of  the  Pelvis 44 

11.  Representing  General  Axis  of  the  Parturient  Canal,  including  the  Uterine 

Cavity  and  Soft  Parts 45 

12.  Side  View  of  Pelvis 46 

13.  Pelvis  of  a  Child 47 

14.  External  Genitals  of  Virgin  with  Diaphragmatic  Hymen.     (After  Sappey.).  49 

15.  Vascular  Supply  of  Vulva.    (After  Kobelt.) 53 

16.  Right  Half  of  Virgin  Vagina  with  Walls  held  apart,  showing  the  abundant 

transverse  Rugae,  the  greater  depth  of  the  Vagina  above  than  below,  and 

the  Hymeneal  Segment.     (After  Hart.) 54 

17.  Longitudinal  Section  of  Body,  showing  Relations  of  Generative  Organs  .    .    .  55 

18.  Transverse  Section  of  Body,  showing  Relations  of  the  Fundus  Uteri    ....  56 

19.  Transverse  Section  of  Uterus 57 

20.  Uterus  and  Appendages  in  an  Infant.     (After  Farre.) 58 

21.  Portion  of  Interior  of  Cervix.     (Enlarged  nine  diameters. ) 59 

22.  Muscular  Fibres  of  unimpregnated  Uterus.     (After  Farre. ) 60 

23.  Developed  Muscular  Fibres  from  the  Gravid  Uterus.     (After  Wagner.)  ...  60 

24.  Lining  Membrane  of  Uterus,  showing  network  of  Capillaries  and  Orifices  of 

Uterine  Glands.     (After  P^'arre.) 62 

25.  'J'lie  Course  of  the  Glands  in  tlie  fully-developed   Mucous  Membrane  of  the 

Uterus.     (After  Williams.) 62 

xxi 


xxii  ILL  USTEA  TIONS. 

FIG.  PAGE 

26.  Vertical  Section   through   the  Mucous  Membrane   of   the   Human   Uterus. 

(After  Turner.) 63 

27.  Villi  of  Os  Uteri  stripped  of  Epithelium.    (After  Tyler  Smith  and  Hassall.j  .  64 

28.  Villi  of  Uterus,  covered  with  Pavement  Epithelium,  and  containing  Looped 

Vessels.     (After  Tyler  Smith  and  Hassall.) 64 

29.  Bifid  Uterus.    (After  Farre.) 66 

30.  Partitioned  Uterus.    (Kussmaul.) 68 

31.  Adult  Parovarium,  Ovary,  and  Fallopian  Tube.     (After  Kobelt.) 69 

32.  Posterior  View  of  Muscular  and  Vascular  Arrangements.     (After  Kouget.)  .  70 

33.  Fallopian  Tube  laid  open.     (After  Kichard.)     . 72 

34.  Ovary  enlarged  under  Menstrual  Nisus 73 

35.  Longitudinal  Section  of  Adult  Ovary.     (After  Farre.) 74 

36.  Section  through  the  Cortical  part  of  the  Ovary.    (After  Turner.) 75 

37.  Vertical  section  through  the  Ovary  of  the  Human  Foetus.     (After  Foulis.)    .  76 

38.  Diagrammatic  Section  of  Graafian  Follicle 77 

39.  Bulb  of  Ovary 78 

40.  Mammary  Gland 79 

41.  Section  of  Ovary,  showing  Corpus  Luteum  three  weeks  after  Menstruation. 

(After  Dalton.) 83 

42.  Corpus  Luteum  at  the  fourth  month  of  Pregnancy.     (After  Dalton.)    ....  84 

43.  Corpus  Luteum  of  Pregnancy  at  Term.     (After  Dalton.) 84 

44.  Section  of  Parts  of  three  Seminiferous  Tubules  of  a  Rat.     (From  a  prepara- 

tion by  Mr.  A.  Frazer.) 96 

45.  Ovum  of  Rabbit  containing  Spermatozoa 97 

46.  Formation  of  the  "  Polar  Globule  " 99 

47.  Segmentation  of  the  Yelk  . 99 

48.  Formation  of  the  Blastodermic  Membrane.     (After  Joulin.) 100 

49.  Aborted  Ovum  (of  about  forty  days),  showing  the  Triangular  Shape  of  the 

Decidua  (which  is  laid  open),  and  the  Aperture  of  the  Fallopian  Tube. 

(After  Coste.) 102 

50.] 

51.  [  Formation  of  the  Decidua.     (After  Dalton.) 102 

52.  J 

53.  An  Ovum  removed  from  the  Uterus,  and  part  of  the  Decidua  Vera  cut  away. 

(After  Coste.) 103 

54.  Diagram  of  Area  Germinativa,  showing  the  Primitive  Trace  and  Area  Pel- 

lucida 105 

55.  Development  of  the  Amnion 106 

56.  Development  of  the  Umbilical  Vesicle  and  Amnion 107 

57.  An  Embryo  of  about  twenty-five  days  laid  ojjen.     (After  Coste.) 107 

58.  Development  of  the  Chorion 108 

59.  Placental  Villus,  greatly  magnified.     (After  Joulin.) 113 

60.  Terminal  Villus  of  Foetal  Tuft,  minutely  injected.     (After  Farre.) 113 

61.  Diagram  representing  a  Vertical  Section  of  the  Placenta.     (After  Dalton.)     .  114 

62.  Diagram  illustrating  the  Mode  in  which  a  Placental  A'illus  derives  a  Cover- 

ing from  the  Vascular  System  of  the  Mother.     (After  Priestley.)    ....  115 

63.  The  Extremity  of  a  Placental  Villus.     (After  Goodsir.) 115 

64.  Anterior  and  Posterior  Fontanelles 121 

65.  Bi-parietal  Diameter,  Sagittal  and  Lambdoidal  Sutures,  with  Posterior  Fonta- 

nelle 121 

66.  Diameters  of  the  Foetal  Skull 122 


ILLUSTRATIONS.  xxiii 

FIG.  PAGE 

67.  Mode  of  Ascertaining  the  Position  of  the  Foetus  by  Palpation 124 

68.  Diagram  illustrating  tlie  Effect  of  Gravity  on  the  Foetus.      (After  Duncan.)  126 

69.  Illustrating  the  greater  Mobility  of  the  Foetus  and  the  larger  relative  amount 

of  Liquor  Amnii  in  Early  Pregnancy.     (After  Duncan.) 126 

70.  Diagram  of  Foetal  Heart.     (After  Dalton.) 129 

71.  Diagram  of  Heart  of  Infant.     (After  Dalton.) 131 

72.  Relations  of  Pregnant  Uterus  at  six  months.     (After  Martin.) 133 

73.  Size  of  Uterus  at  various  Periods  of  Pregnancy 135 

74.  ~] 

75.  I   Supposed  Shortening  of  the  Cervix  at  the  third,  sixth,  eighth,  and  ninth 

76.  I        months  of  Pregnancy,  as  figured  in  Obstetric  Works 136 

77.  J 

78.  Cervix  of  a  Woman  Dying  in  the  Eighth  Month  of  Pregnancy.     (After 

Duncan.) 137 

79.  Appearance  of  the  Areola  in  Pregnancy 147 

80.  Illustrating  the  Cavity  between  the'  Decidua  Vera  and  the  Decidua  Reflexa 

during  the  early  Months  of  Pregnancy.     (After  Coste.) 171 

81.  Tubal  Pregnancy,  with  the  Corpus  Luteum  in  the  Ovary  of  the  opposite  side.  174 
-82.  Tubal  Pregnancy.     (From  a  specimen  in  the  Museum  of  King's  College.)    .  175 

83.  Extra-uterine  Pregnancy  at   term  of  the    Tubo-ovarian  Variety.      (After 

a  case  of  Dr.  A.  Sibley  Campbell's.) 177 

84.  Uterus  and  Fretus  in  a  case  of  Abdominal  Pregnancy 184 

85.  Lithopsedion.     (From  a  preparation  in  the  Museum  of  the  Koyal  College  of 

Surgeons.) 185 

86.  Contents  of  the  Cyst  in  Dr.  Oldham's  case  of  Missed  Labor 194 

87.  Hypertrophied  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal 

Portion.     (After  Duncan.) 227 

88.  Imperfectly  developed  Decidua  Vera,  with  the  Ovum.     (After  Duncan.)  .    .  228 

89.  Hydatidiform  Degeneration  of  the  Chorion 230 

90.  Double  Placenta,  with  Single  Cord 233 

91.  Fatty  Degeneration  of  the  Placenta 234 

92.  Knots  in  the  Umbilical  Cord .  235 

93.  Intra-uterine  Amputation  of  both  Arms  and  Legs 240 

94.  An  Apoplectic  Ovum,  with  Blood  eflused  in  masses  under  the  Foetal  Surface 

of  the  Membranes .    '. 245 

95.  Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Membranes 246 

96.  Mode  in  which  the  Placenta  is  Naturally  Expelled.     (After  Duncan.)  .    .    .  266 

97.  Attitude  of  Child  in  First  Position.    (After  Hodge.) 270 

98.  First  Position :  Movement  of  Flexion 271 

99.  First  Position :  Occiput  in  Cavity  of  Pelvis.     (After  Hodge.) 273 

100.  First  Position  :  Occiput  at  Outlet  of  Pelvis.     (After  Hodge.) 274 

101.  First  Position :  Head  Delivered.     (After  Hodge.) 275 

102.  External  Rotation  of  Head  in  First  Position.     (7\.fter  Hodge.) 275 

103.  Third  Position  of  Occiput  at  Brim  of  Pelvis 276 

104.  Fourth  Position  of  Occiput  at  Pelvic  Brim .  278 

105.  Examination  during  the  First  Stage  of  Labor 282 

106.  Mod^  of  effecting  Relaxation  of  the  Perineum , 288 

107.  Usual  Method  of  Removing  the  Placenta  by  Traction  on  the  Cord     ....  291 

108.  Illustrating  Expression  of  the  Placenta 293 

109.  First,  or  left  Sacro-anterior  position  of  the  Breech 303 

110.  Passage  of  the  Shoulders  and  i)artial  Rotation  of  the  Thorax 304 

111.  Descent  of  the  Head 304 


xxiv  ILLUSTRATIONS. 

FIG.  PAGE 

112.  Third  Position  in  Face  Presentation 313 

113.  Kotation  forward  of  Chin 314 

114.  Passage  of  tiie  Head  through  the  External  Parts  in  Face  Presentation  .    .    .  315 

115.  Illustrating  the  Position  of  the  Head  when  Forward  Rotation  of  the  Chin 

does  not  take  place 315 

116.  Dorso-anterior  Presentation  of  the  Arm 323 

1 17.  Dorso-posterior  Presentation  of  the  Arm 324 

118.  Spontaneous  Evolution.     (After  Chiara.) 329 

119.  Dorsal  Displacement  of  the  Arm 331 

120.  Dorsal  Displacement  of  the  Arm  in  Footling  Presentation.     (After  Barnes.)  331 

121.  Prolapse  of  the  Umbilical  Cord 332 

122.  Postural  Treatment  of  Prolapse  of  the  Cord 334 

123.  Braun's  Apparatus  for  Replacing  the  Cord 336 

124.  Labor  complicated  by  Ovarian  Tumor 358 

125.  Twin  Pregnancy,  Breech  and  Head  presenting 363 

126.  Head  Locking,  both  Children  presenting*  Head  first.     (After  Barnes.)  .    .    .  365 

127.  Head  Locking,   first  Child  coming  Feet  first :    Impaction  of  Heads  from 

wedging  in  Brim.     (After  Barnes. ) 366 

128.  Labor  impeded  by  Hydrocephalus 371 

129.  Adult  Pelvis  retaining  its  Infantile  Type 378 

130.  Scolio-rachitic  Pelvis 379 

131.  Rickety  Pelvis,  with  backward  depression  of  Symphysis  Pubis 380 

132.  Flatness  of  Sacrum,  with  narrowing  of  the  Pelvic  Cavity 381 

133.  Pelvis  deformed  by  Spondylolisthesis.     (After  Kilian.) 381 

134.  [  "             "           "                 "                     (After  Neugebauer.)]      382 

135.  Osteo-malacic  Pelvis 385 

136.  Extreme  degree  of  Osteo-malacic  Deformity 385 

137.  Obliquely-contracted   Pelvis.     (After  Duncan.) 386 

138.  Kyphotic  Pelvis 387 

139.  Robert's,  or  Double  Obliquely-contracted  Pelvis.     (After  Duncan.)     ....  387 

140.  Bony  Growth  from  Sacrum  obstructing  the  Pelvic  Cavity 388 

141.  Greenhalgh's  Pelvimeter 393 

142.  Section  of  Foetal  Cranium,  showing  its  Conical  Form 396 

143.  Showing   the  greater   Breadth  of  the  Bi-parietal  Diameter  of  the  FoBtal 

Cranium.     (After  Simpson.) 396 

144.  Showing  the  greater  Space  for  the  Bi-parietal  Diameter  at  the  side  of  the 

Pelvis  in  certain  Cases  of  Deformity.     (After  Simpson.) 397 

145.  Irregular  Contraction  of  the  Uterus,  with  Encystment  of  the  Placenta  .    .    .  418 

146.  Illustrating  the   Dangerous   Thinning  of  the  Lower  Segment  of  Uterus, 

owing  to  non-descent  of  Plead  in  a  case  of  Intra-uterine  Hydrocephalus. 

(After  Bandl.) 434 

147.  Partial  Inversion  of  the  Fundus 443 

148.  Illustrating  the  Commencement  of  Inversion  at  the  Cervix.    (After  Duncan.)  446 

149.  Barnes's  Bag  for  Dilating  the  Cervix -153 

150.  First  Stage  of  Bi-polar  Version.     (After  Barnes.) 463 

151.  Second  Stage  of  Bi-polar  Version.     (After  Barnes.) 464 

152.  Third  Stage  of  Bi-polar  Version.     (After  Barnes.) •  464 

153.  Fourth  Stage  of  Bi-polar  Version.     (After  Barnes.) 465 

154.  Seizure  of  the  Feet  when  the  Hand  is  introduced  into  the  Uterus 466- 

155.  Drawing  down  of  the  Feet  and  Completion  of  Version 467 

156.  Showing  the  Completion  of  Version.     (After  Barnes.) 469' 

157.  Showing  the  use  of  the  Right  Hand  in  Abdomino-anterior  positions  -        .    •  470- 


ILLUSTRATIONS.  xxv 

FIG.  PAGE 

158.  Denman's  Short  Forceps 473 

159.  Ziegler's  Forceps 473 

160.  Simpson's  Forceps 474 

161.  Tarnier's  Forceps 476 

162.  Simpson's  Axis-Traction  Forceps 476 

163.  Position  of   Patient  for  Forceps  Delivery,  and  Mode  of   Introducing  the 

Lower  Blade 480 

164.  Introduction  of  the  Upper  Blade 481 

165.  Forceps  in  position  ;  Traction   in  the  Axis  of    the  Brim,  downward    and 

backward 482 

166.  Last  Stage  of   Extraction ;   the    Handles  of    the  Forceps  turned  upward 

toward  the  Mother's  Abdomen 483 

167.  Hodge  Forceps 488 

168.  Wallace  Forceps 488 

169.  Davis  Forceps 488 

170.  Elliott  Forceps 490 

171.  Sawyer  Forceps .    .               490 

172.  Application  of  the  Forceps  at  the  Inferior  Strait 491 

173.  Application  of  the  Forceps  with  the  Head  at  the  Superior  Strait,  the  Left 

Blade  held  iu  Place  by  an  Assistant 493 

174.  Direction  of  the  Forceps  as  the  Head  is  being  Delivered 494 

175.  Vectis  with  Hinged  Handle 496 

176.  Wilmot's  Fillet 497 

177.. 

178.  r  Various  Forms  of  Perforators 499 

179.  J 

J^^- j  Crotchets 499 

181.  -* 

182.  Craniotomy  Forceps 499 

183.  Simpson's  Cranioclast 500 

184.  Hicks's  Cephalotribe  ...        501 

185.  Perforation  of  the  Skull 505 

186.  Foetal  Head  crushed  by  Cephalotribe 507 

187.  Professor  Simpson's  Basilyst 508 

188.  Straight  Craniotomy  Forceps 509 

189.  Curved  Craniotomy  Foi'ceps 510 

190.  Method  of  Transfusion  by  Aveling's  Apparatus 541 

191.  Schafer's  Canula  for  Immediate  Transfusion 541 

192.  Section  of  a  Uterine  Sinus  from  the  Placental  vSite  nine  weeks  after  delivery. 

(After  Williams.) 551 


193.1 

194. 

195. 

196. 

197. 

198. 


Temperature  Charts 


r609 
610 
611 
612 
613 

L614 


199.  Hayes's  Tube  for  Intra-uterine  rnjections 615 

/•  Temperature  Charts 616 

201.  J  ^ 


PLATE    I, 


Chtoi  fs_ 


BECTION   or   A   FROZEN   BODY  IN   THE   LAST  MOXTH   OF   PltEGNANCT  (AFTER  BIlAnNE),  ILLUETKATING   THE 

EELATIONS   OF  THE   UTERDS  TO   THE  SUREOUNDINQ    PARTS,  AKD   THE   ATTITUDE   OP    THE 

FtElTS,  ■WHICH   IS   LTINQ   IN    THE   SECOND   CRANIAL   POSITION. 


PLATE    II. 


Ext.  03  Uteri 


Urethri 


ECTION   OP   A    niOZKN    IJODY   AT   TlIK   TKIIMINATIOX   OF   THK   FIRST   STAGE   OP   LABOIl   (aI'TKU    IIRAUNE). 

THE    llAfi    OK  MEMDKANES  IS   BTILL   UNBBOKEN,   Till!   CERVIX   IS   FULLY  DILATED,   AND 

'HIE   UEAD   (in  the  SECOND   POSITION)   IS   IN   THE   PELVIC   CAVITY. 


THE 

SCIENCE    AND    PRACTICE 

OF 

MIDWIFERY. 


PART  I 


ANAT03IY  AND  PHYSIOLOGY  OF  THE   ORGANS 
CONCERNED  IN  PARTURITION 


CHAPTER   I. 

ANATOMY   OF  THE  PELVIS. 

The  pelvis  is  the  bony  basin  situated  between  the  trunk  and  the  lower 
extremities.  To  the  obstetrician  its  study  is  of  paramount  importance, 
for  it  not  only  contains,  in  the  unimpregnated  state,  all  the  organs  con- 
nected with  the  function  of  reproduction,  but  through  its  cavity  the 
foetus  has  to  pass  in  the  process  of  parturition.  An  accurate  knowledge, 
therefore,  of  its  anatomical  formation  may  be  said  to  be  the  very  alpha- 
bet of  obstetrics,  without  which  no  one  can  practise  midwifery,  either 
with  satisfaction  to  himself  or  safety  to  his  patient. 

In  a  treatise  on  obstetrics,  however,  any  detailed  account  of  the  purely 
descriptive  anatomy  of  the  pelvis  would  be  out  of  place.  A  knowledge 
of  that  must  be  taken  for  granted,  and  it  is  only  necessary  to  refer  to 
those  points  which  have  a  more  or  less  direct  bearing  on  the  study  of 
its  obstetrical  relations. 

The  pelvis  is  formed  of  four  bones.  On  either  side  are  the  ossa  inno- 
minata,  joined  together  ])y  the  sacrum  ;  to  the  inferior  extremity  of  tlie 
sacrum  is  attached  the  coccyx,  which  is,  in  fact,  its  continuation. 

The  OS  innominafum  (Fig.  1)  is  an  irregularly  shaped  bone  originally 
fjrmed  of  throe  distinct  portions,  the  iliam,  the  ischium,  and  the  pubes, 
wliich  remain  s<;paratcd  from  each  other  uj)  to  and  Ixyond  the  jx'riod  of 
puberty.  They  an;  united  at  the  acetabiiliun  by  a  Y-shaped  cartilagi- 
nous junction,  wliich  does  not,  as  a  rule,  hecc^me  ossified  until  about  the 
twentieth  year.  Tlie  conse(jU(!nce  is  that  the  pelvis,  during  the  jx'i'iod 
of  growth,  is  subject  to  the  action  of  various  mechanical  influences  to  a 

3  33 


34 


ORGANS  CONCERNED  IN  PARTURITION. 


far  greater  extent  than  in  adult  life ;  and  tliese,  as  we  shall  presently  see, 
have  an  important  effect  in  determining  the  form  of  the  bones.  The 
external  surface  and  borders  of  the  os  innominatum  are  chiefly  of  obstet- 
ric interest  from  giving  attachment  to  nuiscles,  many  of  which  have  an 
important  accessory  influence  on  parturition,  such  as  the  muscles  form- 
ing the  abdominal  wall,  which  are  attached  to  its  crest,  and  those  closing 
its  outlet  and  forming  the  perineum,  which  are  attached  to  the  tuberosity 
of  the  ischium.  On  the  anterior  and  posterior  extremities  of  the  crest 
of  the  ilium  are  two  prominences  (the  anterior  and  posterior  spinous 
processes)  which  are  points  from  ^vhich  certain  measurements  are  some- 
times taken.     The  internal  surface  of  the  upper  fan-shaped  portion  of 

Fig.  1. 


Os  Innominatum. 


the  OS  innominatum  gives  attachment  to  the  iliacus  muscle,  and  contrib- 
utes to  the  support  of  the  abdominal  contents  ;  along  with  its  fellow  of 
the  opposite  side  it  forms  the  false  pelvis.  Tlie^dse^is  separated  from 
the  true  pelvis  by^thejlio-pectineal  line,  which,  with  the  upper  niargin 
of  the  sacrum,  forms  the  brim  of  the  pelvis.  This  is  of  especial  obstetric 
importance,  as  it  is  the  first  part  of  the  pelvic  cavity  through  ^^■hich  the 
child  passes,  and  that  in  which  osseous  deformities  are  most  often  met 
with.  At  one  portion  of  the  ilio-pectineal  line,  corresponding  with  the 
junction  of  the  ilium  and  pubes,  is  situated  a  prominence  which  is 
known  as  the  ilio-pectinea_l_emmence. 

Infernal  Surface. — The  internal  smooth  surfiice  of  the  innominate 
bone  below  the  linea  ilio-pectinea  forms  the  greater  portion  of  the  pelvis 
proper.  In  front,  with  the  corresponding  portions  of  the  opposite  bone, 
it  forms  the  arch  of  the  pubes,  under  which  the  head  of  the  child  pa.sses 
in  labor. 

Behind  this  we  observe  the  oval  obturator  foramen,  and  beloAv  that 
the  tuberosity  and  spine  of  the  ischium,  the  latter  separating  the  great 
and  lesser  sciatic  notches,  and  giving  attachment  to  ligaments  of  imjiort- 
auce.  The  rough  articulating  surface  posteriorly,  by  which  the  junction 
with  the  sacrum  is  effected,  may  be  noted,  and  above  this  the  prominence 


ANA  TO  31 Y  OF  THE  PELVIS. 


35 


Fig.  2. 


Sacrum  and  Coccyx. 


to  which  the  powerful  ligaments  joining  the  sacrum  and  os  innominatum 
are  attached. 

The  sacrum  (Fig.  2)  is  a  triangular  and  somewhat  spongy  bone  form- 
ing the  continuation  of  the  spinal  column  and  binding  together  the  ossa 
innoniinata.  It  is  originally  composed  of 
five  separate  portions,  analogous  to  the 
vertebrge,  which  ossify  and  unite  about  the 
period  of  puberty,  leaving  on  its  internal 
surface  four  prominent  ridges  at  the  points 
of  junction.  The  upper  of  these  is  .some- 
times so  well  marked  as  to  be  mistaken, 
on  vaginal  examination,  for  the  promontory 
of  the  sacrum  itself. 

The  base  of  the  sacrum  is  about  4|- 
inches  in  width,  and  its  sides  rapidly  ap- 
proximate until  they  nearly  meet  at  its 
apex,  giving  the  whole  bone  a  triangular 
or  wedge  shape.  The  anterior  and  pos- 
terior surfaces  also  approximate  in  the 
same  way,  so  that  the  bone  is  much  thicker 
at  the  base  than  at  the  apex.  The  sacrum, 
in  the  erect  position  of  the  body,  is  directed 
from  above  downward  and  from  before 
backward.  At  its  upper  edge  it  is  joined,  the  lumbo-sacral  cartilage 
intervening,  with  the  fifth  lumbar  vertebra.  Thepoint  of  junction, 
ca]y^d_tW  promontory  of  the  sacrum,  is  of  great  importance,  as  on  its 
undue  projection  many  deformities  of  the  brim  of  the  pelvis  depend . 
The  anterior^rface"  of  the  bone  is  concave,  and  forms  the  curve  of  the 
sacrum — more  marked  in  some  cases  than  in  others.  There  is  also  more 
or  less  concavity  from  side  to  side.  On  it  we  observe  four  apertures  on 
each  side,  the  intervertebral  foramina,  giving  exit  to  nerv^es.  The  pos- 
terior surface  is  convex,  rough  and  irregular  for  the  attachment  of  liga- 
ments and  muscles,  and  showing  a  ridge  of  vertical  prominences  corre- 
sponding to  the  spinous  processes  of  the  vertebrae. 

Mechanical  Relations  of  the  Sacrum. — The  sacrum  is  generally 
described  as  forming  a  keystone  to  the  arch  constituted  by  the  pelvic 
bones,  and  transmitting  the  weight  of  the  body,  in  consequence  of  its 
wedge-like  shape,  in  a  direction  which  tends  to  thrust  it  downward  and 
backward,  as  if  separating  the  ossa  innoniinata.  Dr.  Duncan,^  however, 
has  shown,  from  a  careful  consideration  of  its  mechanical  relations,  that 
it  sliould  rather  be  regarded  as  a  strong  transverse  beam,  curved  on  its 
anterior  surfiice,  the  extremities  of  which  are  in  contact  with  the  corre- 
sponding articular  surfaces  of  the  ossa  innoniinata.  The  weight  of  the 
body  is  thus  transmitted  to  the  innominate  bones,  and  through  them  to 
the  a(;etal)ida  and  the  femora  (Fig.  '>).  There  counter-])rcssure  is 
ap]>lied,  and  the  result  is,  as  wo  shall  subsequently  see,  an  important 
modifying  influence  on  the  development  and  shape  of  the  pelvis. 

'i'lu!  (■or.c.jjx  (Fig.  2)  is  comjiosed  of  four  small  separate  bones,  which 
(!ventually  unite  into  one,  but  not  until  late  in  life.     The  uppermost  of 

'  lirsrarrJicH  in,  Ohxtrtricx,  p.  ()7. 


36  ORGANS  COXCERXED  IN  PARTURITION. 

tliese  articulates  with  the  apex  of  tlie  sacrum.  On  its  posterior  surface 
are  two  small  cornua,  which  unite  with  correspondino;  j)oints  at  the  tip 
of  the  sacrum.     The  bones  of  the  coccyx  taper  to  a  point.     To  it  are 

I  attached  various  muscles  which  have  the  effect  of  imparting  consider- 
able mobility.  During  labor,  also,  it  yields  to  the  mechanical  pressure 
of  the  presenting  part,  so  as  to  increase  the  antero-posterior  diameter  of 
the  pelvic  outlet  to  the  extent  of  an  inch  or  more. 

Ossificdfion  of  Coccyx. — If,  through  disease  or  accident,  as  sometimes 
happens,  the  articular  cartilages  of  the  coccyx  become  prematurely  ossi- 
fied, the  enlargement  of  the  pelvic  outlet  during  labor  may  be  prevented, 
and  considerable  difficitlty  may  thus  arise.  This  is  most  apt  to  happen 
in  aged  primiparse  or  in  women  who  have  followed  sedentary  occupations ; 
and  not  infrequently,  under  such  circumstances,  the  bone  fractures  under 
the  pressure  to  \vhich  it  is  subjected  by  the  presenting  part. 

Pelvic  Articulations. — The  pelvic  bones  are  firmly  joined  together  by 
various  articulations  and  ligaments.  The  latter  are  arranged  so  as  to 
complete  the  canal  through  which  the  foetus  has  to  pass,  and  which  is 
in  great  part  formed  by  the  bones.  On  its  internal  surface,  wdiere  the 
absence  of  obstruction  is  of  importance,  they  are  everywhere  smooth ; 
while  externally,  where  strength  is  the  desideratum,  they  are  arranged  in 
larger  masses,  so  as  to  unite  the  bones  firmly  together.  The  pelvic 
articulations  have  been  generally  described  as  symphyses  or  amphi- 
arthrodia — a  term  which  is  properly  applied  to  tAvo  articulating  surfaces 
united  by  fibrous  tissue  in  such  a  way  as  to  prevent  any  sliding  motion. 
It  is  certain,  however,  that  this  is  not  the  case  with  the  joints  of  the 
female  pelvis  during  pregnancy  and  parturition.     Lenoir  found  that  in 

.  22  females  between  the  ages  of  18  and  35  there  was  a  distinct  sliding 

(motion.  Therefore,  the  pelvic  articulations  are,  strictly  speaking,  to  be 
considered  examples  of  the  class  of  joints  termed  arthrodia. 

Lumbosacral  Joint. — The  last  lumbar  vertebra  is  united  to  the  sacrum 
by  ligamentous  union  similar  to  that  which  joins  the  vertebrae  to  each 
other.  The  intervening  fibro-cartilage  forms  a  disk  Avhich  is  thicker  in 
front  than  behind,  and  this,  in  connection  with  a  similar  peculiarity  of 
the  fifth  lumbar  vertebra,  tends  to  increase  the  sloped  position  of  the 
sacrum  and  the  angle  which  it  forms  with  the  vertebral  column.  It 
constitutes  the  most  prominent  portion  of  the  promontory  of  the  sacrum, 
and  is  the  part  on  which  the  finger  generally  impinges  in  vaginal  exam- 
inations. The  anterior  common  vertebral  ligament  passes  over  the 
surface  of  the  joints,  and  we  also  find  the  ligamenta  subflava  and  the 
interspinous  ligaments,  as  in  the  other  vertebrae.  The  articular  pro- 
cesses are  joined  together  by  a  fibrous  capsule,  and  there  is  also  a  peculiar 
ligament,  the  lumbo-sacral,  extending  from  the  transverse  process  of  the 
vertebra  on  each  side,  and  attaching  itself  to  the  sides  of  the  sacrum  and 
the  sacro-iliac  synchondrosis. 

Ligaments  of  Coccyx. — The  sacrum  is  joined  to  the  coccyx,  and,  in 
some  cases  at  least,  the  separate  bones  of  the  coccyx  to  each  other,  by 
small  cartilaginous  disks  like  that  connecting  the  sacrum  with  the  last 
lumbar  vertebra.  They  are  further  united  by  anterior  and  posterior 
common  ligaments,  the  latter  being  much  the  thicker  and  more  marked. 
In  the  adult  female  a  svnovial  membrane  is  found  between  the  sacrum 


ANATOMY  OF  THE  PELVIS. 


37 


and  coccyx,  and  it  is  supposed  that  this  is  formed  under  the  influence 
"oT  the  movements  of  the  bones  on  each  other. 

Sacro-iliac  Synchondrosis. — The  opposing  articular  surfaces  of  the 
sacrum  and  ihum  are  each  covered  by  cartilages,  that  of  the  sacrum 
being  the  thicker.  These  are  firmly  united,  but,  in  the  female,  accord- 
ing to  Mr.  Wood,^  they  are  always  more  or  less  separated  by  an  inter- 
vening synovial  membrane.  Posterior  to  these  cartilaginous  convex 
surfaces  there  are  strong  interosseous  ligaments  passing  directly  from 
bone  to  bone,  filling  up  the  interspace  between  them  and  uniting  them 
firmly.  There  are  also  accessory  ligaments,  such  as  the  superior  and 
anterior  sacro-iliac,  which  are  of  secondary  consequence.  The  posterior 
sacro-iliac  ligaments,  however,  are  of  great  obstetric  importance.  They 
are  the  very  strong  attachments  which  unite  the  rough  surfaces  on 
the  posterior  iliac  tuberosities  to  the  posterior  and  lateral  surfaces  of  the 
sacrum.  They  pass  obliquely  downward  from  the  former  points,  and 
suspend,  as  it  were,  the  sacrum  from  them.  According  to  Duncan,  the 
sacrum  has  nothing  to  prevent  its  being  depressed  by  the  weight  of  the 
body  but  these  ligaments,  and  it  is  mainly  through  them  that  the  weight 

Fig.  3. 


Section  of  Pelvis  and  Heads  of  Thi^h-bones,  showing  the  Suspensory  Action  of  the  Sacro-iliac 

Ligaments.    (After  Wood.) 

of  the  body  is  transmitted  to  the  sacro-cotyloid  beams  and  the  heads  of 
the  femora. 

Hacro-scidtlc  IJgaments. — The  sacro-sciatic  ligaments  are  instrumental 
in  completing  the  canal  of  the  pelvis.  The  greater  sacro-sciatic  liga- 
ment is  attached  l)y  a  broad  base  to  the  posterior-inferior  spine  of  the 
ilium  and  to  the  posterior  surfaces  of  tlie  sacnun  and  coccyx.  Its  fibres 
ujiite  into  a  thick  cord,  cross  each  other  in  an  X-like  mann(>r,  and  again 

'  Todd's  C'ycJojKrjlid  of  yinalomy  and  I'/iyslolorjij,  iirticle  "Pelvi.s,"  p.  123. 


38  ORGANS  CONCERNED   IN  PARTURITION. 

expand  at  their  insertion  into  the  tuberosity  of  tlie  ischium.  The  lesser 
sacro-soiatie  lii>anient  is  also  attached  with  the  former  to  the  back  parts 
of  the  sacrum  and  coccyx,  its  fibres  passing  to  their  much  narrower 
insertion  at  the  spine  of  the  ischium,  and  conyerting  the  sacro-sciatic 
notch  into  a  complete  foramen. 

Obturator  3Iembrane. — The  obturator  membrane  is  the  fibrous  apon- 
eurosis that  closes  the  large  obturator  foramen.  Joulin  ^  supposes  that, 
along  with  the  sacro-sciatic  ligaments,  it  may,  by  yielding  somewhat  to 
the  pressure  of  the  foetal  head,  tend  to  prevent  the  contusion  to  which 
the  soft  parts  would  be  subjected  if  they  were  compressed  between  two 
entirely  osseous  surfaces. 

Symphysis  Pubis. — The  junction  of  the  pubic  bones  in  front  is  eflPected 
by  means  of  two  oyal  plates  of  fibro-cartilage,  attached  to  each  articular 
surface  by  nipple-shaped  projections,  which  fit  into  corresponding  depres- 
sions in  the  bones.  There  is  a  greater  separation  between  the  bones  in 
front  than  behind,  where  the  numerous  fibres  of  the  cartilaginous  plates 
intersect  and  unite  the  bones  firmly  together.  At  the  upper  and  back 
part  of  the  articulation  there  is  an  interspace  between  the  cartilages 
which  is  lined  by  a  delicate  membrane.  In  pregnancy  this  space  often 
increases  in  size,  so  as  to  extend  even  to  the  front  of  the  joint.  The 
juncture  is  further  strengthened  by  four  ligaments — the  anterior,  the 
posterior,  the  superior,  and  the  subpubic.  Of  these  the  last  is  the 
largest,  connecting  together  the  pubic  bones  and  forming  the  upper 
boundary  of  the  pubic  arch. 

Movements  of  Pelvic  Joints. — The  close  apposition  of  the  bones  of  the 
pelyis  might  not  unreasonably  lead  to  the  supposition  that  no  move- 
ment took  place  between  its  component  parts ;  and  this  is  the  opinion 
which  is  even  yet  held  by  many  anatomists.  It  is  tolerably  certain, 
ho\\ever,  that  even  in  the  unimpregnated  condition  there  is  a  certain 
amount  of  mobility.  Thus,  Zaglas  has  pointed  out^  that  in  man  there 
is  a  movement  in  an  antero-posterior  direction  of  the  sacro-iliac  joints 
which  has  the  eifect,  in  certain  positions  of  the  body,  of  causing  the 
sacrum  to  jiroject  downward  to  the  extent  of  about  a  line,  thus  narroAv- 
ing  the  pelvic  brim,  tilting  up  the  point  of  the  bone,  and  thereby  enlarg- 
ing the  outlet  of  the  pelvis.  This  movement  seems  habitually  bpought 
into  play  in  the  act  of  straining  during  defecation. 

Observations  in  the  Lower  Animals. — During  pregnancy  in  some  of  the 
lower  animals  there  is  a  very  marked  movement  of  the  pelvic  articula- 
tions, which  materially  facilitates  the  process  of  parturition.  This,  in 
the  case  of  the  guinea-pig  and  cow,  has  been  especially  pointed  out  by 
Dr.  JSlatthews  Duncan.^  In  the  former,  during  labor  the  pelvic  b.ones 
separate  from  each  other  to  the  extent  of  an  inch  or  more.  In  the  latter, 
the  movements  are  different,  for  the  symphysis  pubis  is  fixed  by  bony 
ankylosis,  and  is  innnovable ;  but  the  sacro-iliac  joints  become  swollen 
during  pregnancy,  and  extensive  movements  in  an  antero-posterior  direc- 
tion take  place  in  them  which  materially  enlarge  the  pelvic  canal  during 
labor. 

'  IVnile  d'Accouchevievts,  p.  11. 

^  A/ontlily  Journal  of  Med.  Science,  Sept.,  1851. 

"*  Researches  in  Obstetrics,  p.  19. 


ANAT03rY  OF  THE  PELVIS. 


39 


Mode  in  lohich  the  Movements  are  Effected. — It  is  extremely  probable 
that  similar  movements  take  place  in  women,  both  in  the  symphysis 
pubis  and  in  the  sacro-iliac  joints,  although  to  a  less  marked  extent. 
These  are  particularly  well  described  by  Dr.  Duncan.  They  seem  to 
consist  chiefly  in  an  elevation  and  depression  of  the  symphysis  pubis, 
either  by  the  ilia  moving  on  the  sacrum,  or  by  the  sacrum  itself  under- 
going a  forM^ard  movement  on  an  imaginary  transverse  axis  passing 
through  it,  thus  lessening  the  pelvic  brim  to  the  extent  of  one  or  even 
two  lines,  and  increasing,  at  the  same  time,  the  diameter  of  the  outlet  by 
tilting  up  the  apex  of  the  sacrum.  These  movements  are  only  an  exag- 
geration of  those  which  Zaglas  describes  as  occurring  normally  during 
defecation.  The  instinctive  positions  which  the  parturient  woman 
assumes  find  an  explanation  in  these  observations.  During  the  first 
stage  of  labor,  when  the  head  is  passing  through  the  brim,  she  sits  or 
stands  or  walks  about,  and  in  these  erect  positions  the  symphysis  pubis 
is  depressed  and  the  brim  of  the  pelvis  enlarged  to  its  utmost.     As  the 

Fig.  4. 


Outlet  of  Pelvis. 


head  advances  through  the  cavity  of  the  pelvis,  she  can  no  longer 
maintain  her  erect  position,  and  she  lies  down  and  bends  her  body 
forward,  which  has  the  effect  of  causing  a  nutatory  motion  of  the  sac- 
rum, with  corresponding  tilting  up  of  its  apex  and  an  enlargement  of 
the  outlet. 

Alterations  in  the  Pelvic  Joints  during  Pregnancy. — These  movements 
during  j^arturition  are  facilitated  by  the  changes  which  are  known  to 
take  place  in  the  pelvic  articulations  during  pregnancy.  The  ligaments 
and  cartilages  become  swollen  and  softened,  and  the  synovial  membranes 
existing  l)etween  the  articulating  surfaces  become  greatly  augmented  in 
size  and  distended  with  fluid.  These  changes  act  by  forcing  the  bones 
a))art,  as  the  swelling  of  a  sj)<)ng(!  ]ila('ed  between  them  might  do  after 
it  had  iiiil)il)ed  moisture.  The  reality  of  these  alterations  receives  a 
clinical  illustration  from  those  cases,  which  are  far  from  nn(»mmon,  in 
which  these  changes  are  carried  to  so  extreme  an  extent  that  the  power 
of  ])r(jgression  is  materially  interfered  with  for  a  considerable  time  after 
delivery. 


40 


ORGANS  CONCERNED  IN  PARTURITION. 


Pelvis  as  a  Whole. — On  looking  at  the  pelvis  as  a  whole,  we  are  at 
once  struck  with  its  division  into  the  true  and  false  pelvis.  The  latter 
portion  (all  that  is  above  the  brim  of  the  pelvis)  is  of  comparatively  lit- 
tle obstetric  importance,  except  in  giving  attachments  to  the  accessory 
muscles  of  parturition,  and  need  not  be  further  considered.  The  brim 
of  the  pelvis  is  a  heart-shaped  opening,  bounded  by  the  sacrum  behind, 

Fig.  5. 


The  Female  Pelvis. 


the  linea  ilio-pectinea  on  either  side,  and  the  symphysis  of  the  pubes  in 
front.  All  below  it  forms  the  cavity,  which  is  bounded  by  the  hollow 
of  the  sacrum  behind,  by  the  inner  surfaces  of  the  innominate  bones  at 
the  sides  and  in  front,  and  by  the  posterior  surface  of  the  symphysis 
pubis.     It  is  in  this  part  of  the  pelvis  that 


the  changes  in  direction 


Fi&.  6. 


The  Male  Pelvis. 


which  the  foetal  he  ad  undergoes  in  labor  are  imparted  to  it.  The  lower 
border  of  this  canal,  or  pelvic  outlet  (Fig.  4),  is  lozenge-shaped,  is 
bounded  by  the  ischiatic  tuberosities  on  either  side,  the  tip  of  the  coccyx 
behind,  and  the  under  surface  of  the  pubic  symphysis  in  front.  Pos- 
teriorly to  the  tuberosities  of  the  ischia  the  boundaries  of  the  outlet  are 
completed  by  the  sacro-sciatic  ligaments. 


ANATOMY  OF  THE  PELVIS. 


41 


Difference  in  the  Two  Sexes. — There  is  a  very  marlved  difference  between 
the  pelvis  in  the  male  and  the  female,  and  the  peculiarities  of  the  latter  all 
tend  to  facilitate  the  process  of  parturition.  In  the  female  pelvis  (Fig.  5) 
all  the  bones  are  lighter  in  structure,  and  have  the  points  for  muscular 
attachments  much  less  developed.  The  iliac  bones  are  more  spread  out, 
hence  the  greater  breadth  which  is  observed  in  the  female  figure,  and  the 
peculiar  side-to-side  movement  which  all  females  have  in  walking.  The 
tuberosities  of  the  ischia  are  lighter  in  structure  and  farther  apart,  and 
the  rami  of  the  pubes  also  converge  at  a  much  less  acute  angle.  This 
greater  breadth  of  the  pubic  arch  gives  one  of  the  most  easily  appreciable 
points  of  contrast  between  the  male  and  the  female  pelvis ;  the  pubic 
arch  in  the  female  forms  an  angle  of  from  90°  to  100°,  while  in  the 
male  (Fig.  6)  it  averages  from  70°  to  75°.  The  obturator  foramina 
are  more  triangular  in  shape. 

The  whole  cavity  of  the  female  pelvis  is  wider  and  less  funnel-shaped 
than  in  the  male,  the  symphysis  pubis  is  not  so  deep,  and,  as  the  promon- 
tory of  the  sacrum  does  not  project  so  much,  the  shape  of  the  pelvic 
brim  is  more  oval  than  heart-shaped.  These  differences  between  the 
male  and  female  pelvis  are  probably  due  to  the  presence  of  the  female 

Ficx.  7. 


Brim  of  Pelvis,  showing  Antero-posterior,  Oblique,  and  Conjugate  Diameters. 


genital  organs  in  the  true  pelvis,  the  groM^th  of  which  increases  its 
development  in  Avidth.  In  proof  of  this,  Schroeder  states  that  in  women 
with  congenitally  defective  internal  organs,  and  in  women  who  have  had 
both  ovaries  removed  early  in  life,  the  pelvis  has  always  more  or  less 
of  the  masculine  type. 

Measurements  of  the  Pelvis. — The  measurements  of  the  pelvis  that 
are  of  most  importance  from  an  obstetric  point  of  view  are  taken  between 
various  points  directly  ojijiosite  to  ea(;h  other,  and  arc  known  as  the 
fJiarneters  of  the  pelvis.  Those  of  the  true  jx'lvis  are  the  diameters 
which  it  is  cs])ecially  important  to  fix  in  our  memories,  and  it  is  cus- 
tomary to  describe  tlu^ee  in  Avorks  on  obstetrics — the  antero-posterior  or 
conjugate,  the  oblif)ne,  and  the  transverse — although  of  ccjurse  the  meas- 
urements may  be  taken  at  any  o[iposing  ])oints  in  the  circumference  of  the 
bones.     The  antero-posterior  (sacro-|)iibic),  at  the  brim  (Fig.  7),  is  taken 


42 


OEGAXS  CONCERNED  IN  FABTUBITION. 


Fjo 


from  the  upper  part  of  the  posterior  surface  of  the  synijiliysis  pubis  to 
the  centre  of  the  proniontorv  of  the  sacrum  ;  in  the  cavity,  from  the  cen- 
tre of  the  symphysis  pubis  to  a  cor- 
responding point  in  the  body  of  the 
tliird  piece  of  the  sacrum ;  and  at 
the  outlet  (coccy-pubic),  from  the 
lower  border  of  the  symphysis  pubis 
to  the  tip  of  the  coccyx.  The  oblique, 
at  the  brim,  is  taken  from  the  sacro- 
iliac joint  on  either  side  to  a  point 
of  the  brim  corresjjonding  with  the 
ilio-pectineal  eminence  (that  starting 
from  the  right  sacro-iliac  joint  being 
called  the  right  oblique,  that  from 
the  left  the  left  oblique) ;  in  the 
cavity  a  similar  measurement  is  made 
at  the  same  level  as  the  conjugate, 
while  at  the  outlet  an  oblique  diame- 
ter is  not  usually  measured.  The 
h-ansverse  is  taken  at  the  brim,  from 
a  point  midway  bet^^een  the  sacro- 
iliac joint  and  the  ilio-pectineal  emi- 
nence to  a  corresponding  point  at  the 
opposite  side  of  the  brim  ;  in  the  ca\'- 
ity  from  points  in  the  same  plane  as 
the  conjugate  and  oblique  diameters  ; 
and  at  the  outlet  from  the  centre 
of  the  inner  border  of  one  ischial 
tuberosity  to  that  of  the  other. 
The  measurements  given  by  various 
w^'iters  differ  considerably  and  vary 
somewhat  in  different  pelves.  Tak- 
ing the  average  of  a  large  number, 
the  following  may  be  given  as  the 
standard  measurements  of  the  female 
pelvis : 

Aiitero-posterior(iu.)-         Oblique  (iu.).  Tiaiisverse  (in.). 

Brim 4.25 4.8 5.2 

Cavity 4.7 5.2 4.75 

Outlet 5.0    : 4.2 

Differences  in  Various  Parts  of  Pelvis. — It  will  be  observed  that  the 
lengths  of  the  corresponding  diameters  at  diiferent  places  vary  greatly  ; 
thus,  while  the  transverse  is  longest  at  the  brim,  the  oblique  is  longest 
in  the  cavity  and  the  antero-posterior  at  the  outlet.  It  will  be  subse- 
quently seen  that  this  fiict  is  of  great  practical  importance  in  studying 
the  mechanism  of  delivery,  for  the  head  in  its  descent  through  the  pelvis 
alters  its  position  in  such  a  way  as  to  adapt  itself  to  the  longest  diam- 
eter of  the  pelvis ;  thus,  as  it  passes  through  the  cavity  it  lies  in  the 
oblique  diameter,  and  then  rotates  so  as  to  be  expelled  in  the  antero- 
posterior diameter  of  the  outlet. 


Transverse  Section  of  Pelvis,  showing  the 
Diameters. 


ANATOMY  OF  THE  PELVIS. 


43 


Diameters  as  Altered  by  /^oft  Parts. — In  thinking  of  these  measure- 
ments of  the  pelvis  it  must  not  be  forgotten  that  they  are  taken  in  the 
dried  bones,  and  that  they  are  considerably  modified  during  life  by  the 
soft  parts.  This  is  especially  the  case  at  the  brim,  where  the  projection 
of  the  psoas  and  iliacus  muscles  lessens  the  transverse  diameter  about 
half  an  inch,  while  the  antero-posterior  diameter  of  the  brim  and  all  the 
diameters  of  the  cavity  are  lessened  by  a  quarter  of  an  inch.  The  right 
oblique  diameter  of  the  brim  is,  even  in  the  dried  pelvis,  found  to  be  on 
an  average  slightly  longer  than  the  left,  jjrobably  on  account  of  the 
increased  development  of  the  right  side  of  the  pelvis  from  the  greater 
use  made  of  the  right  leg ;  but  in  addition  to  this  the  left  oblique  diam- 
eter is  somewhat  lessened  during  life  by  the  presence  of  the  rectum  on 
the  left  side.  The  advantage  gained  by  the  comparatively  frequent 
passage  of  the  head  through  the  pelvis  in  the  right  oblique  diameter  is 
thus  explained. 

Other  Measurements. — There  are  one  or  two  other  measurements  of  the 
true  pelvis  which  are  sometimes  given,  but  which  are  of  secondary 
importance.  One  of  these,  the  sacro-cotyloid  diameter,  is  that  between 
the  promontory  of  the  sacrum  and  a  point  immediately  above  the  coty- 

FiG.  9. 


Planes  of  the  Pelvis  with  Horizon. 

A  B.     Horizon.  c  n.     Vertical  line. 

A  B  I.     Angle  of  inclination  of  pelvis  to  horizon,  equal  to  (10°. 

B  I  c.     Angli;  (if  initliiiation  of  pelvis  to  spinal  column,  equal  to  150°. 

C  I  J.     .^nK!(•  of  hicliiiation  of  sacrum  to  spinal  column,  equal  to  130°. 

E  r.     Axis  of  pelvic  inlet.  I,  M.     Mid  plane  in  tlie  middle  line. 

N.     Lowest  point  of  mid  plane  of  ischium. 

loid  cavity,  and  averages  from  3.4  to  3.5  inches.  Another,  called  by 
Wood  the  lower  or  in(!lin(!d  conjugate  diameter,  is  that  between  the 
centre  of  the  lower  margin  of  the  symj)]iysis  pubis  and  the  promontory 


44  ORGANS  CONCERNED  IN  PARTURITION. 

of  the  sacrum,  and  averages  half  an  inch  more  than  the  antero-posterior 
diameter  of  the  brim.  These  measurements  are  chiefly  of  importance 
in  relation  to  certain  pelvic  deformities. 

External  Measurements. — The  external  measurements  of  the  pelvis 
are  of  no  real  consequence  in  normal  parturition,  but  they  may  help  us, 
in  certain  cases,  to  estimate  the  existence  and  amount  of  deformities. 
Those  which  are  generally  given  are :  Between  the  anterior-superior 
iliac  spines,  10  inches ;  between  the  central  points  of  the  crests  of  the 
ilia,  10^  inches;  between  the  spinous  process  of  the  last  lumbar  vertebra 
and  the  up})er  part  of  the  symphysis  pubis  (external  conjugate),  7  inches. 

Planes  of  the  Pelvis. — By  the  planes  of  the  pelvis  are  meant  imaginary 
levels  at  any  portion  of  its  circumference.  If  we  were  to  cut  out  a  piece 
of  cardboard  so  as  to  fit  the  pelvic  cavity,  and  place  it  either  at  the  brim 

Fig.  10. 


Axes  of  the  Pelvis. 

A.  .\xis  of  superior  plane.  b.  Axis  of  niiil  ijlatie.  c.  Axis  of  inferior  plane. 

D.  Axis  of  canal.  e.  Horizon. 

or  elsewhere,  it  would  represent  the  pelvic  plane  at  that  particular  part, 
and  it  is  obvious  that  we  may  conceive  as  many  planes  as  we  desire. 
Observation  of  the  angle  which  the  pelvic  planes  form  with  the  horizon 
.shows  the  great  obliquity  at  M'hich  the  pelvis  is  placed  in  regard  to  the 
spinal  column.  Thus  the  angle  a  B  i  (Fig.  9)  represents  the  inclination 
to  the  horizon  of  the  plane  of  the  pelvic  brim,  i  B,  and  is  estimated  to 
be  about  60°,  while  the  angle  which  the  same  plane  forms  with  the  ver- 
tebral column  is  about  150°.  The  plane  of  the  outlet  forms,  with  the 
coccyx  in  its  usual  position,  an  angle  with  the  horizcm  of  about  11°,  but 
which  varies  greatly  with  the  movements  of  the  tip  of  coccyx  and  the 
degree  to  which  it  is  ]-)Ushed  l)ack  during  parturition.  These  figures 
nuist  onlv  be  taken  as  giving  an  approximate  idea  of  the  inclination  of 
the  pelvis  to  the  s])inal  column,  and  it  nnist  be  remembered  that  the 
degree  of  inclination  varies  considerably  in  the  same  female  at  different 


ANATOMY  OF  THE  PELVIS. 


45 


times,  in  accordance  with  the  position  of  the  body.  During  pregnancy 
especially,  the  obliquity  of  the  brim  is  lessened  by  the  patient  throwing 
herself  backward  in  order  to  support  more  easily  the  weight  of  the 
gravid  uterus.  The  height  of  the  promontory  of  the  sacrum  above  the 
upper  margin  of  the  symphysis  pubis  is  on  an  average  about  3|  inches, 
and  a  line  passing  horizontally  backward  from  the  latter  point  would 
impinge  on  the  junction  of  the  second  and  third  coccygeal  bones. 

Axes  of  the  Parturient  Canal. — By  the  axis  of  the  pelvis  is  meant  an 
imaginary  line  which  indicates  the  direction  which  the  foetus  takes 
during  its  expulsion.  The  axis  of  the  brim  (Fig.  10)  is  a  line  drawn 
perpendicular  to  its  plane,  which  would  extend  from  the  umbilicus  to 
about  the  apex  of  the  coccyx ;  the  axis  of  the  outlet  of  the  bony  pelvis 
intersects  this,  and  extends  from  the  centre  of  the  promontory  of  the 
sacrum  to  midway  between  the  tuberosities  of  the  ischia.  The  axis  of 
the  entire  pelvic  canal  is  represented  by  the  sum  of  the  axes  of  an  indef- 
inite number  of  planes  at  different  levels  of  the  pelvic  cavity,  which 
forms  an  irregular  parabolic  line,  as  represented  in  the  diagram  (Fig. 
10,  A  d). 

Fig  U. 


Representing  General  Axis  of  Parturient  Canal,  including  the  Uterine  Cavity  and  Soft  Parts. 

It  must  1)6  borne  in  mind,  however,  that  it  is  not  tlic  axis  of  the  bony 
pelvis  alone  that  is  of  iinj>()i'tMiH'c  in  obstetrics.  We  must  always,  in 
considering  this  subject,  remember  that  the  general  axis  of  the  parturient 
canal  (Fig.  11)  also  includes  that  of  the  uterine  cavity  above  and  of  the 
soft  ])arts  below.  These  are  variable  in  direction  ac(!ording  to  circum- 
stances;  and  it  is  only  the  axis  of  that  portion  of  tlic  parturient  canal 
extending  between  the  plane  of  the  pelvic  bi'im  and  a  plane  between  the 


46 


ORGANS  CONCERNED  IN  PARTURITION. 


lower  edge  of  the  pubic  symphysis  and  the  base  of  the  coeeyx  that  is 
fixed.  The  axis  of  the  lower  part  of  the  canal  will  vary  according  to 
the  amount  of  distension  of  the  perineum  during-  labor ;  but  when  this  is 
stretched  to  its  utmost,  just  before  the  expulsion  of  the  head,  the  axis  of 
the  plane  between  the  edge  of  the  distended  perineum  and  the  lower 
border  of  the  symphysis  looks  nearly  directly  forward.  The  axis  of 
the  uterine  cavity  generally  corresponds  ^vit]l  that  of  the  pelvic  brim, 
but  it  may  be  much  altered  by  abnormal  positions  of  the  uterus,  such  as 
anteversion  from  laxity  of  the  abdominal  walls.  The  foetus,  under  such 
circumstances,  will  not  enter  the  brim  in  its  proper  axis,  and  difficulties 
in  the  labor  arise.  A  knowledge  of  the  general  direction  of  the  par- 
turient canal  is  of  great  importance  in  practical  midwifery  in  guiding  us 
to  the  introduction  of  the  hand  or  instruments  in  obstetric  operations, 
and  in  showing  us  how  to  obviate  difficulties  arising  from  such  acci- 
dental deviations  of  the  uterus  as  have  been  just  alluded  to. 

Cavity  of  the  Pelvis. — The  arrangements  of  the  bones  in  the  interior 
of  the  pelvic  canal  (Fig.  12)  are  important  in  relation  to  the  mechanism 

of  delivery.     A  line  passing  between 
Fig.  12.  the  spine  of  the  ischium  and  the  ilio- 

pectineal  eminence  divides  the  inner  sur- 
face of  the  ischial  bone  into  two  smooth 
plane  surfaces,  which  have  received  the 
name  of  the  planes  of  the  ischium. 
Two  other  planes  are  formed  by  the 
inner  surfaces  of  the  pubic  bones  in 
front  and  by  the  upper  portion  of  the 
sacrum  behind,  both  having  a  direction 
dowuA^ard  and  back^^ ard.  In  studying 
the  mechanism  of  delivery,  it  will  be 
seen  that  many  obstetricians  attribute 
to  these  planes,  in  conjunction  with  the 
spines  of  the  ischia,  a  very  important 
influence  in  effecting  rotation  of  the 
Side  View  of  Pelvis.  fcetal  head  from  the  oblique  to  the  an- 

tero-posterior  diameter  of  the  pelvis. 
Development  of  the  Pelvis. — The  peculiarities  of  the  pelvis  during 
infancy  and  childhood  are  of  interest  as  leading  to  a  kno^vledge  of  the 
manner  in  which  the  form  observed  during  adult  life  is  impressed  upon 
it.  The  sacrum  in  the  pelvis  of  the  child  (Fig.  13)  is  less  developed 
transversely,  and  is  nmch  less  deeply  curved,  than  in  the  adult.  ^  The 
pubes  is  also  much  shorter  from  side  to  side,  and  the  pubic  arch  is  an 
acute  angle.  The  result  of  this  narrowness  of  both  the  pubes  and 
sacrum  is  that  the  transverse  diameter  of  the  pelvic  brim  is  shorter 
instead  of  longer  than  the  antero-posterior.  The  sides  of  the  pelvis 
have  a  tendency  to  parallelism,  as  well  as  the  antero-posterior  Avails  ; 
and  this  is  stated  by  Wood  to  be  a  peculiar  characteristic  of  the  infantile 
pelvis.  The  iliac  bones  are  not  spread  out  as  in  adult  life,  so  that  the 
centres  of  the  crests  of  the  ilia  are  not  more  distant  from  each  other 
than  the  anterior-superior  spines.  The  cavity  of  the  true  pelvis  is 
small,  and  the  tuberosities  of  the  ischia  are  proportionately  nearer  to 


ANATOMY  OF  THE  PELVIS. 


47 


each  other  than  they  afterward  become ;  the  pelvic  viscera  are  conse- 
quentlj  crowded  up  into  the  abdominal  cavity,  which  is,  for  this  reason, 
much  more  prominent  in  children  than  in  adults.  The  bones  are  soft 
and  semi-cartilaginous  until  after  '  the  period  of  puberty,  and  yield 
readily  to  the  mechanical  influences  to  which  they  are  subjected ;  and 
the  three  divisions  of  the  innominate  bone  remain  separate  until  about 
the  twentieth  year. 

As  the  child  grows  older  the  transverse  development  of  the  sacrum 
increases,  and  the  pelvis  begins  to  assiune  more  and  more  of  the  adult 
shape.  The  mere  gro^vth  of  tli^  bones,  hoAvever,  is  not  sufficient  to 
account  for  the  change  in  the  shape  of  the  pelvis,  and  it  has  been  well 


Fig.  13. 


Pelvis  of  a  Child. 


shown  by  Duncan  that  this  is  chiefly  produced  by  the  pressure  to  which  the 
bones  are  subjected  during  early  life.  The  iliac  bones  are  acted  upon  by 
two  principal  and  opposing  forces.  One  is  the  weight  of  the  body  above, 
which  acts  vertically  upon  the  sacral  extremity  of  the  iliac  beam  through 
the  strong  posterior  sacro-iliac  ligaments,  and  tends  to  throw  the  lower 
or  acetabular  ends  of  the  sacro-cotyloid  beams  outward.  This  outward 
displacement,  however,  is  resisted,  partly  by  the  junction  between  the 
two  acetabular  ends  at  the  frcnit  of  the  pelvis,  but  chiefly  by  the  oppos- 
ing force,  which  is  the  upward  pressure  of  the  loA^'er  extremities  through 
the  femurs.  The  result  of  these  counteracting  forces  is  that  the  still  soft 
bones  bend  near  their  junctic^i  with  the  sacrum,  and  thus  the  greater 
transverse  development  of  the  jielvic  brim  characteristic  of  adult  life  is 
established.  In  treating  of  pelvic  deformities  it  will  be  seen  that  the 
same  forces  aj)plied  to  di.seased  aud  softened  bones  ex])lain  tlie  jx-cnliari- 
ties  of  form  that  they  assume. 

Pelr/s  ill  Different  Rfices. — Tli(i  researches  that  iiavc  been  made  on 
tlie  differem-es  of  the  pelvis  in  diflerent  races  j)rove  tiiat  these  are  not  so 
great  as  might  have  been  expected.  Jouliu  pointed  out  that  in  all 
human  jielvcs  the  transverse  diameter  was  larger  than  the  antero-pos- 
tcrior,  whik;  the  rev(;rs(!  was  the  case  in  all  the  lower  animals,  even  in 
the  liighest  simitc.     This  observation  has  been  more  recently  confirmed 


48  ORGANS  CONCERNED  IN  PARTURITION. 

by  Yon  Franque/  who  has  made  careful  measurements  of  tlie  pelvis  in 
various  races.  In  the  pelvis  of  the  gorilla,  the  oval  form  of  the  brim, 
resulting  from  the  increased  length  of  the  conjugate  diameter,  is  very 
marked.  In  certain  races  there  is  so  far  a  tendency  to  animality  of  type 
that  the  difference  between  the  transverse  and  conjugate  diameters  is 
nuich  less  than  in  European  women,  but  is  not  sufficiently  marked  to 
enable  us  to  refer  any  given  pelvis  to  a  particular  race.  Von  Franque 
makes  the  general  observation  that  the  size  of  the  pelvis  increases  from 
south  to  north,  but  that  the  conjugate  diameter  increases  in  proportion 
to  the  transverse  in  southern  races.   * 

Soft  Parts  in  connection  ivith  Pelvis. — In  closing  the  description  of  the 
pelvis  the  attention  of  the  student  must  be  directed  to  the  muscular  and 
other  structures  which  cover  it.  It  has  already  been  pointed  out  that 
the  measurements  of  the  pelvic  diameters  are  considerably  lessened  by 
the  soft  parts,  which  also  influence  parturition  in  other  ways.  Thus, 
attached  to  the  crests  of  the  ilia  are  strong  muscles  which  not  only  sup- 
jDort  the  enlarged  uterus  during  pregnancy,  but  are  powerful  accessory 
muscles  in  labor :  in  the  pelvic  cavity  are  the  obturator  and  pyriformis 
muscles  lining  it  on  either  side ;  the  pelvic  cellular  tissue  and  fasciae ; 
the  rectum  and  bladder;  the  vessels  and  nerves,  pressure  on  which 
often  gives  rise  to  cramps  and  pains  during  pregnancy  and  labor ;  while 
below  the  outlet  of  the  pelvis  is  closed  and  its  axis  directed  forward  by 
the  numerous  muscles  forming  the  floor  of  the  pelvis  and  perineum. 
The  structures  closing  the  pelvis  have  been  accurately  described  by  Dr. 
Berry  Hart,^  who  points  out  that  they  form  a  complete  diaphragm 
stretching  from  the  pelvis  to  the  sacrum,  in  which  are  three  "  faults  " 
or  "  slits  "  formed  by  the  orifices  of  the  urethra,  vagina,  and  rectum. 
The  first  of  these  is  a  mere  capillary  slit,  the  last  is  closed  by  a  strong 
muscular  sphincter,  while  the  vagina,  in  a  healthy  condition,  is  also  a 
mere  slit,  with  its  walls  in  accurate  apposition.  Hence  it  follows  that 
none  of  these  apertures  impairs  the  structural  efficiency  of  the  pelvic 
floor  or  the  support  it  gives  to  the  structures  above  it. 


CHAPTER   II. 

THE  FEMALE  GENERATIVE  ORGANS. 

Division  according  to  Function. — The  reproductive  organs  in  the 
female  are  conveniently  divided,  according  to  their  function,  into — 1. 
The  external  or  copulative  organs,  which  are  chiefly  concerned  in  the 
act  of  insemination,  and  are  only  of  secondary  importance  in  parturi- 
tion :  they  include  all  the  organs  situated  externally  which  form  the 
vulva ;  and  the  vagina,  Mdiicli  is  placed  internally  and  forms  the  canal 

^  Scanzoiii's  Beitrage,  1867. 

^  The  Structural  Anatomy  of  tlte  Female  Pelvic  Floor. 


THE  FEMALE  GENERATIVE   ORGANS. 


49 


of  communication  between  the  uterus  and  the  vulva.  2.  The  internal 
or  formative  organs :  they  include  the  ovaries,  which  are  the  most  im- 
portant of  all,  as  being  those  in  ^diich  the  ovule  is  formed ;  the  Fal- 
lopian tubes,  through  which  the  ovule  is  carried  to  the  uterus ;  and  the 
uterus,  in  which  the  impregnated  ovule  is  lodged  and  developed. 

1.  The  external  organs  consist  of — 

Mons  Veneris. — The  mons  veneris  (Fig.  14,/)  is  a  cushion  of  adipose 
and  fibrous  tissue  which  f^rms  a  rounded  projection  at  the  upper  part  of 
the  vulva.  It  is  in  relation  above  with  the  lower  part  of  the  hypogas- 
tric region,  from  which  it  is  often  separated  by  a  furrow,  and  below  it  is 
continuous  with  the  labia  majora  on  either  side.  It  lies  over  the  sym- 
physis and  horizontal  rami  of  the  pubes.     After  puberty  it  is  covered 

Fig.  14. 


\:> 


pii;iim> ' 


External  Genitals  of  Virgin  with  Diaphragmatic  Hymen.   (After  Sappey.) 

a.  Labium  majus.        h.  Laliiiini  niiiius.        c.  Pnnpiitium  clituiiilis.        <l.  Glans  clitoridis. 

e.  Vestibule  just  above  iireth ml  orifice.        /.  INInns  veneris. 

with  hair.     On  its  integument  are  found  the  openings  of  numerous 
sweat  and  sebaceous  glands. 

LaJna  Majora. — The;  lahia,  majora  (Fig.  1 4,  a)  form  two  symmetrical 
sides  to  the  longitudinal  aj)erture  of  the  vulva.  They  have  two  surfaces 
■ — one  external,  of  ordinary  integument,  covered  with  hair,  and  another 
Internal,  of  smooth  nuicous  nicmbrane,  in  aj)i)osition  with  the  correspond- 


{ 


50  ORGANS  CONCERNED  IN  PARTURITION. 

ing  portion  of  the  opposite  labium,  and  separated  from  the  external  surface 
by  a  free  convex  border.  They  are  thicker  in  front,  where  they  run  into 
the  mons  veneris,  and  thinner  behind,  m  here  thev  are  united,  in  front  of  the 
t-^'-  7  perineum,  by  a  thin  fold  of  inteiiument  called  the  iourchet1;e.  which  is 
♦»*-*4  almost  invariably  ru])tured  in  the  first  labor.  In  the  virgin  the  labia 
are  closely  in  apposition  and  conceal  the  rest  of  the  generative  organs. 
After  childbearing  they  become  more  or  less  separated  from  each  other, 
and  in  the  aged  they  waste  and  the  internal  nymphse  protrude  through 
them.  Both  their  cutaneous  and  mucous  surfaces  contain  a  large  num- 
ber  of  sebaceous  glands,  opening  either  directly  on  the  surface  or  into 
the  hair-follicles.  In  structure  the  labia  are  composed  of  (Connective 
tissue,  containing  a  varying  amount  of  fat,  and  parallel  with  their  exter- 
nal surface  are  placed  tolerably  close  plexuses  of  elastic  tissue,  inter- 
spersed with  regularly  arranged  smooth  muscular  fibres.  These  fibres 
are  described  by  Broca  as  forming  a  membranous  sac  resembling  the 
dartos  of  the  scrotum,  to  which  the  labia  majora  are  analogous.  Toward 
its  upper  and  narrower  end  this  sac  is  continuous  with  the  external 
inguinal  ring,  and  in  it  terminate  some  of  the  fibres  of  the  round  liga- 
ment. The  analogy  with  the  scrotum  is  further  borne  out  by  the  occa- 
sional hernial  protrusion  of  the  ovary  into  the  labium,  corresponding  to 
the  normal  descent  of  the  testis  in  the  male. 

Labia  Minora. — The  labia  minora,  or  nymphce  (Fig.  14,  b),  are  two 
folds  of  mucous  membrane,  commencing  below,  on  either  side,  about  the 
centre  of  the  internal  surftice  of  the  labium  externum  ;  they  converge  as 
they  proceed  upward,  bifurcating  as  they  approach  each  other.  The 
., lower  branch  of  this  bifurcation  is  attached  to  the  clitoris  (Fig.  14,  c), 
while  the  upper  and  larger  unites  with  its  fellow  of  the  opposite  side, 
and  forms  a  fold  round  the  clitoris  known  as  its  ])repuce.  The  nyraphse 
are  usually  entirely  concealed  by  the  labia  majora,  but  after  childbearing 
and  in  old  age  they  project  some\\hat  beyond  them  ;  then  they  lose  their 
delicate  pink  color  and  soft  texture,  and  become  brown,  dry,  and  like 
skin  in  appearance.  This  is  especially  the  case  in  some  of  the  negro 
races,  in  whom  they  form  long  projecting  folds  called  the  apron. 

.  The  surfaces  of  the  nymphse  are  covered  with  tessellated  e])ithelium, 
and  over  them  are  distributed  a  large  number  of  vascular  paiiillge,  some- 
what enlarged  at  their  extremities,  and  sebaceous  glands,  which  are. 
more  numerous  on  their  internal  surfiices.  The  latter  secrete  an  odor- 
ous, cheesy  matter,  which  lubricates  the  surface  of  the  vulva  and  pre- 
vents its  folds  adhering  to  each  other.  The  nymphse  are  composed  of 
trabeculse  of  connective  tissue  containing  muscular  fibres. 

The  Clitoris. — The  clitoris  (Fig.  14,  d)  is  a  small  erectile  tubercle 
situated  about  half  an  inch  below  the  anterior  commissure  of  the  labia 
majora.  It  is  the  analogue  of  the  penis  in  the  male,  and  is  similar  to  it 
in  structure,  consisting  of  two  corpora  cavernosa,  separated  from  each 
other  by  a  fibrous  septum.  The  crura  are  covered  by  the  ischio-cavern- 
ous  muscles,  which  serve  the  same  purpose  as  in  the  male.  It  has  also 
a  suspensory  ligament.  The  corpora  cavernosa  are  composed  of  a  vas- 
cular plexus  with  numerous  traversing  muscular  fibres.  The  arteries 
are  derived  from  the  internal  pudic  artery,  which  gives  a  branch,  the 
cavernous,  to  each  half  of  the  organ  ;  there  is  also  a  dorsal  artery  dis- 


THE  FEMALE  GENERATIVE  ORGANS.  51 

tributed  to  the  prepuce.  According  to  Gussenbauer,  these  cavernous 
arteries  pour  their  blood  directly  into  large  veins,  and  a  finer  venous 
plexus  near  the  surface  receives  arterial  blood  from  small  arterial 
branches.  By  these  arrangements  the  erection  of  the  organ  which  takes 
place  during  sexual  excitement  is  favored.  The  nervous  supply  of  the 
clitoris  is  large,  being  derived  from  the  internal  pudic  nerve,  which  sup- 
plies  branches  to  the  corpora  cavernosa,  and  terminates  in  the  glands  and 
prepuce,  where  Paccinian  corpuscles  and  terminal  bulbs  are  to  be  found. 
On  this  account  the  clitoris  has  been  supposed  by  some  to  be  the  t^hipf 
seat  of  voluptuous  sensation  in  the  female.    ^'^^  /^>*—  ^  /^J^  /^^SC  O^^^ 

The    Vedibule — The    vestibule    (Fig.   14,   e)    is   a   triangular   space,  "^^ 

bounded  at  its  apex  by  the  clitoris  and  on  either  side  by  the  folds  of  the 
nymphse.  It  is  smooth,  and,  unlike  the  rest  of  the  vulva,  is  destitute 
of  sebaceous  glands,  although  there  are  several  groups  of  muciparous 
glaiids  opening  on  its  surface.  At  the  centre  of  the  base  of  the  triangle, 
which  is  formed  by  the  upper  edge  of  the  opening  of  the  vagina,  is  a 
prominence,  distant  about  an  inch  from  the  clitoris,  on  which  is  the  ori- 
fice of  the  urethra.  This  prominence  can  be  readily  made  out  by  the 
finger,  and  the  depression  upon  it — leading  to  the  urethra — is  of  import- 
ance as  our  guide  in  passing  the  female  catheter.  This  little  operation 
ought  to  be  performed  without  exposing  the  patient,  and  it  is  done  in 
several  ways.  The  easiest  is  to  place  the  tip  of  the  index  finger  of  the 
left  hand  (the  patient  lying  on  her  back)  on  the  apex  of  the  vestibule, 
and  slip  it  gently  down  until  we  feel  the  bulb  of  the  urethra  and  the 
dimple  of  its  orifice,  which  is  generally  readily  found.  If  there  is  any 
difficulty  in  finding  the  orifice,  it  is  well  to  remember  that  it  is  placed 
immediately  below  the  sharp  edge  of  the  lower  border  of  the  symphy- 
sis pubis,  which  will  guide  us  to  it.  The  catheter  (and  a  male  elastic 
catheter  is  always  the  best,  especially  during  labor,  when  the  urethra  is 
apt  to  be  stretched)  is  then  passed  under  the  thigh  of  the  patient  and 
directed  to  the  orifice  of  the  urethra  by  the  finger  of  the  left  hand,  which 
is  placed  upon  it.  We  must  be  careful  that  the  instrument  is  really 
passed  into  the  urethra,  and  not  into  the  vagina.  It  is  advisable  to 
have  a  few  feet  of  elastic  tubing  attached  to  the  end  of  the  catheter,  so 
that  the  urine  can  be  passed  into  a  vessel  under  the  bed  without  uncov- 
ering the  patient.  If  the  patient  be  on  her  side,  in  the  usual  obstetric 
position,  the  operation  can  be  more  readily  performed  by  placing  the  k 
tip  of  the  finger  in  the  vagina  and  feeling  its  upper  edge.  The  orifice  i 
of  the  urethra  lies  immediately  above  this,  and  if  the  catheter  be  slipped  V 
along  the  palmar  surface  of  the  finger,  it  can  generally  be  inserted  with-  ) 
out  much  trouble.  If,  however,  as  is  often  the  case  during  labor,  the 
parts  are  nui(;h  swollen,  it  may  be  difficult  to  find  the  aperture,  and  it  is 
then  always  better  to  look  for  the  opening  than  to  hurt  the  patient  by 
lf>ng-continued  efforts  to  feel  it. 

lite  UrefJmi. — The  urethra  is  a  canal  1 1  inches  in  length,  and  it  is 
i nt i mately . c(7nnected  with  the  anterior  wairT)!"  the  vagina,  through  which 
it  may  be  felt.  It>  is  (;om|)()sed  of  muscular  and  erectile  tissue,  and  is 
remarkable  for  its  extreme  dilatability — a  |)roperty  which  is  turned  to 
practical  account  in  some  of  the  operations  fin*  stone  in  the  female 
bladder. 


52  ORGANS  CONCERNED  IN  PARTURITION. 

Orifice  of  the  Yadlna. — The  orifice  of  the  vagina  is  situated  immedi- 
ately  below  the  bulb  of  the  urethra.  In  virgins  it  is  a  circular  opening, 
but  in  women  who  have  borne  children  or  practised  sexual  intercourse 
it  is,  in  the  undistended  state,  a  fissure,  running  transversely  and  at 
right  angles  to  that  between  the  labia.^  In  virgins  it  is  generally  more 
or  less  blocked  up  by  a  fold  of  mucous  membrane,  containing  some 
cellular  tissue  and  muscular  fibres,  with  vessels  and  nerves,  which_is 
kno^vn  as  the  hymen.  This  is  most  often  crescentic  in  shape,  with  the 
concavity  of  the  crescent  looking  upward ;  sometimes,  however,  it  is  cir- 
cular with  a  central  opening,  or  cribriform  :  or  it  may  even  be  entirely 
im]jerforate,  and  this  gives  rise  to  the  retention  of  the  menstrual  secre- 
tion. These  varieties  of  form  depend  on  the  peculiar  mode  of  develop- 
ment of  the  fold  of  vaginal  mucous  membrane  which  blocks  up  the 
orifice  of  the  vagina  in  the  foetus,  and  from  which  the  hymen  is  formed. 
The  density  of  the  membrane  also  varies  in  different  individuals.  INIost 
usually  it  is  very  slight,  so  as  to  be  ruptured  in  the  first  sexual 
approaches,  or  even  by  some  accidental  circumstance,  such  as  stretching 
the  limbs,  so  that  its  absence  cannot  be  taken  as  evidence  of  want  of 
chastity.  A  knowledge  of  this  fact  is  of  considerable  importance  from 
a  medico-legal  point  of  view.  Sometimes  it  is  so  tough  as  to  prevent 
intercourse  altogether,  and  may  require  division  by  the  knife  or  scissors 
before  this  can  be  effected  ;  ancl  at  others  it  rather  unfolds  than  ruptures, 
so  that  it  may  exist  even  after  impregnation  has  been  eifected,  and  it  has 
been  met  with  intact  in  women  who  have  habitually  led  unchaste  lives. 
In  a  few  rare  cases  it  has  even  formed  an  obstacle  to  delivery,  and  has 
required  incision  during  labor. 

Ca) -un cuke  llyrti formes. — The  caruncuke  myrtiformes  are  small  fleshy 
tubercles,  varying  from  two  to  five  in  number,  situated  around  the  orifice 
of  the  vagina,  and  which  are  generally  supposed  to  be  the  remains 
of  the  ruptured  hymen.  Schroeder,  however,  maintains  that  they  are 
only  formed  after  childbearing  in  consequence  of  parts  of  the  hymen 
having  been  destroyed  by  the  injuries  received  during  the  passage  of  the 
child. 

Vulvo-vaain al  Gkm ds. — Near  the  posterior  part  of  the  vaginal  orifice, 
and  below  the  superficial  perineal  fascia,  are  situated  two  conglomerate 
glands  which  are  the  analogues  of  Cowper's  glands  in  the  male.  Each 
of  these  is  about  the  size  and  shape  of  an  almond,  and  is  contained  in  a 
cellular  fibrous  envelope.  Internally  they  are  of  a  yellowish-white  color, 
and  are  composed  of  a  number  of  lobules  separated  from  each  other  by 
prolongations  of  the  external  envelope.  These  give  origin  to  separate 
ducts  which  unite  into  a  common  canal,  about  half  an  inch  in  length, 
which  opens  in  front  of  the  attached  edge  of  the  hymen  in  virgins,  and 
in  married  women  at  the  base  of  one  of  the  carunculse  myrtiformes. 
According  to  Huguier,  the  size  of  the  glands  varies  much  in  different 
women,  and  they  appear  to  have  some  connection  with  the  ovary,  as  he 
has  always  found  the  largest  gland  to  be  on  the  same  side  as  the  largest 
ovary.  They  secrete  a  glairy,  tenacious  fluid,  which  is  ejected  in  jets 
during  the  sexual  orgasm,  probably  through  the  spasmodic  action  of  the 
perineal  muscles.     At  other  times  their  secretion  serves  the  purpose  of 

^  Hart,  op.  cif. 


THE  FEMALE  GENERATIVE  ORGANS. 


53 


-^^-<^xJi 


lubricating  the  vulva,  and  thus  preserves  the  sensibility  of  its  mucous 
membrane. 

Fossa  Navicularis. — Immediately  behind  the  hymen  in  the  unmarried,  f^^-^Vv 
and  between  it  and  the  perineum,  is  a  small  depression  called  the  fossa  }*^^u^/tj, 
navieularis,  which  disappears  after  childbearing.  ^^T^^ ^' 

Perineum. — The  perineum  separates  the  orifice  of  the  vagina  from  that 
of  the  rectum.  It  is  about  1-|-  inches  in  breadth,  and  is  of  great  obstetric 
interest,  not  only  as  supportrng  the  internal  organs  from  below,  but 
because  of  its  action  in  labor.  It  is  largely  stretched  and  distended  by 
the  presenting  part  of  the  child,  and  if  unusually  tough  and  unyielding 
may  retard  delivery,  or  it  may  be  torn  to  a  greater  or  less  extent,  thus 
giving  rise  to  various  subsequent  troubles. 

VasGidar  Siq^j^ly  of  the  Vulva. — The  structures  described  above 
together  form  the  vulva,  and  they  are  remarkable  for  their  abundant  vas- 

FiG.  15. 


Vascular  Supply  of  Vulva.   (After  Kobelt.) 

n.  Bulb  of  vestibule.    6.  Muscular  tissue  of  vagina,    c,  d,  e,  f.  The  clitoris  auil  muscles,     g,  h,  i,  Jc,  1,  m,  n. 

Veins  of  the  nymphae  and  clitoiis  communicating  with  the  epigastric  and  obturator  veins. 

cular  and  nervous  supply.  The  former  constitutes  an  erectile  tissue, 
similar  to  that  which  has  already  been  described  in  the  clitoris,  and 
which  is  especially  marked  about  the  bulb  of  the  vestibule  (Fig.  16). 
From  this  point  and  extending  on  either  side  of  the  vagina  there  is  a 
well-marked  plexus  of  convoluted  veins,  which,  in  their  distended  state, 
are  likened  by  Dr.  Arthur  Farre  to  a  filled  leech.  The  erection  of  the 
erectile  tissue,  as  well  as  that  of  the  clitoris,  is  brought  about  under 
excitement,  as  in  the  male,  by  the  compression  of  the  efferent  veins  by 
the  contraction  of  th(!  is(;hio-cav(!riious  mus(;les,  and  by  that  of  a  thin 
layer  of  muscular  tissues  surrounding  the  orifice  of  the  vagina  and 
described  as  the  constrictor  vaginae. 


54 


ORGANS  CONCERNED  IN  PARTURITION. 


The  Var/ina. — The  vagina  is  the  canal  which  forms  the  communica- 
tion between  tlie  external  and  internal  generative  organs,  through  which 
the  semen  passes  to  reach  the  uterus,  the  menses  flow,  and  the  ffjetus  is 
expelled.     Roughly  speaking,  it  lies  in  the  axis  of  the  pelvis,  but  its 
opening  is  placed  anterior  to  the  axis  of  the  pelvic  outlet,  so  that  its 
lower  portion  is  curved  forward,  so  as  to  lie  parallel  to  the  j^elvic  brim. 
It  is  narrow  below,  but  dilated  above,  where  the  cervix  uteri  is  inserted 
^  ^^'   I  into  it,  so  that  it  is  more  or  less  conoidal  in  shape.     Under  ordinary  cir- 
■JJ^^  j  cumstances,  especially  in  the  virgin,  the  anterior  and  posterior  walls  lie 
'  in  close  contact  with  each  other  (see  Plate  I.),  and  there  is,  strictly  speak- 
ing, no  vaginal  canal,  although  they  are  capable  of  wide  distension,  as  in 
copulation  and  during  the  passage  of  the  foetus.     The  anterior  wall  of 
the  vagina  is  shorter  than  the  posterior,  the  former  measuring  on  an 
average  2^  inches,  the  latter  3  inches  ;  but  the  length  of  the  canal  varies 
greatly  in  different  subjects  and  under  certain  circumstances.     In  front 
the  vagina  is  closely  connected  with  the  base  of  the  bladder,  so  that 
when  the  vagina  is  prolapsed,  as  often  occurs,  it  drags  the  bladder  with 
it  (Fig.  17)  ;  behind,  it  is  in  relation  with  the  rectum,  but  less  intimately ; 
laterally  with  the  broad  ligaments  and  pelvic  fascia ;  and  superiorly  with 
.the  lower  portion  of  the  uterus  and  folds  of  peritoneum  both  before  and 
behind.      The  vagina  is  composed  of  mucous,  muscular,  and  cellular 
coats.     The  mucous  lining  is  thrown  into  numerous  folds.     These  start 
from  longitudinal  ridges  which  exist  on  both  the  anterior  and  posterior 
^Js^*"  '  walls,  but  most  distinctly  on  the  anterior.     They  are  very  numerous  in 
''^    the  young  and  unmarried,  and  greatly  increase  the  sensitive  surface  of 
the  vagina  (Fig.  16).    After  childbearing,  and  in  the  aged,  they  become 

Fig.  16. 


Eis^ht  Half  of  Virsin  Vasjina,  with  Walls  held  apart,  showing  the  abundant  Transverse  Rugae, 
the  greater  depth  of  the  Vagina  above  than  below,  and  the  Hymenlal  Segment.  (Alter  Mart.) 

atrophied,  but  they  never  completely  disappear,  and  toward  the  orifice 
of  the  vagina,  where  they  exist  in  greatest  abundance,  they  are  always 
to  be  met  M'ith.  The  whole  of  the  mucous  membrane  is  lined  with  tes- 
sellated epithelium,  and  it  is  covered  with  a  large  number  of  papillae, 


THE  FEMALE  GENERATIVE  ORGANS. 


55 


either  conical  or  divided,  which  are  highly  vascular  and  project  into  the 
epithelial  layer.  Unlike  the  vulvar  mucous  membrane,  that  of  the 
vagina  seems  to  be  destitute  of  glands.  Beneath  the  epithelial  layer  is 
a  submucous  tissue  containing  a  large  number  of  elastic  and  some  mus- 
cular fibres,  derived  from  the  muscular  walls  of  the  vagina.  These  are 
strong  and  well  developed,  especially  toward  the  ostium  vaginse.  They 
consist  of  two  layers — an  internal  longitudinal  and  an  external  circular — 
with  oblique  decussating  fibres  connecting  the  two.  Below  they  are 
attached  to  the  ischio-pubic  rami,  and  above  they  are  continuous  with 
the  muscular  coat  of  the  uterus.     The  muscular  tissue  of  the  vagina 

Fig.  17. 


Longitudinal  Section  of  Body,  showing  Relations  of  Generative  Organs. 

increases  in  thickness  during  pregnancy,  but  to  a  much  less  degree  than 
that  of  the  uterus.  Its  vascular  arrangements,  like  those  of  the  vulva, 
are  such  as  to  constitute  an  erectile  tissue.  The  arteries  form  an  intricate 
network  around  the  tube,  and  eventually  end  in  a  submucous  capillary 
])lexus  fhjiii  which  twigs  })ass  to  supply  the  papillse ;  these  again  give 
origin  to  venous  radicles  which  luiitc  into  meshes  freely  interlacing  with 
each  other  and  forming  a  well-marked  venous  plexus. ' 

2.  The  Iiifcnial  Orf/dii.s  of  (Iciwrdfioii. — The  internal  organs  of  gen- 
eration c(jnsist  <jf  th(;  uterus,  the  Falloi)ian  tubes,  and  the  ovaries ;  and 
in  connection  with  them  we  have  to  study  the  various  ligaments  and 
folds  of  peritoneum  which  serve  to  maintain  the  organs  in  position, 
along  with  certain  a('(!(;ssory  structures.  Physiologically,  the  most  im- 
portant of  all  the  generative  organs  are  the  ovaries,  in  which  the  ovules 


56 


OBGANS  CONCERNED  IN  PAETUIUTION. 


are  formed,  and  ^\'llich  dominate  the  entire  reproductive  life  of  the 
female.  The  Fallopian  tubes,  which  convey  the  ovule  to  the  uterus, 
and  the  uterus  itself — whose  main  function  is  to  receive,  nourish,  and 
eventually  expel  the  impregnated  prcxluct  of  the  ovary — may  be  said  to 
be,  in  fact,  accessory  to  these  viscera.  Practically,  however,  as  obstet- 
ricians, we  are  chiefly  concerned  ^^'ith  the  uterus,  and  may  conveniently 
commence  with  its  description. 

The  Uterus, — The  uterus  is  correctly  described  as  a  pyriform  organ, 
flattened  from  before  backward,  consisting  of  the  body,  with  its  rounded 
I  fundus,  and  the  cervix,  which  projects  into  the  upper  part  of  the  vaginal 
I  canal.  In  the  adult  female  it  is  deeply  situated  in  the  pelvis,  being 
placed  between  the  bladder  in  front  and  the  rectum  behind,  its  fundus 
being  below  the  plane  of  the  pelvic  brim  (Fig.  18).  It  only  assumes 
this  position,  however,  toward  the  period  of  puberty ;  and  in  the  foetus 
it  is  placed  much  higher,  and  lies,  indeed,  entirely  within  the  cavity  of 
the  abdomen.     It  is  maintained  in  this  position  partly  by  being  slung 


Transverse  Section  of  the  Body,  showing  Relations  of  the  Fundus  Uteri. 
m.  Pubes.    a  a  (in  front).  Remainder  of  liypogastric  arteries,     o  a  (beliinii).  Spermatic  vessels  and  nerves. 
B.  Bladder.     L  L.  Round  ligaments.     U.  Fundus  uteri,     t,  t.  Fallopian  tubes,     o,  o.  Ovaries,    r.  Rectum. 
g.  Right  ureter,  resting  on  the  psoas  muscle,     c.  Utero-sacral  ligaments,     v.  Last  lumbar  vertebra. 

by  its  ligaments,  which  we  shall  subsequently  study,  and  partly  by  being 
supported  from  below  by  the  pelvic  cellular  tissue  and  the  fleshy  column 
of  the  vagina.  The  result  is  that  the  uterus,  in  the  healthy  female,  is  a 
perfectly  movable  body,  altering  its  position  to  suit  the  condition  of  the 
surrounding  viscera,  especially  the  bladder  and  rectum,  which  are  sub- 
jected to  variations  of  size  according  to  their  fulness  or  emptiness. 
When  from  any  cause — as,  for  example,  some  peri-uterine  inflammation 
producing  adhesions  to  the  surrounding  textures — the  mobility  of  the 
organ  is  interfered  with,  much  distress  ensues,  and  if  pregnancy  super- 
venes more  or  less  serious  consequences  may  result.    Generally  speaking, 


THE  FEMALE  GENERATIVE   ORGANS. 


57 


the  uterus  may  be  said  to  lie  in  a  line  roug^Iily  corresiponding  with  the 
axis  of  the  pelvic  brim,  its  fundus  being  pointed  forward,  and  its  cervix 
lying  in  such  a  direction  that  a  line  drawn  from  it  would  impinge  on 
the  junction  between  the  sacrum  and  coccyx.  According  to  some 
authorities,  the  uterus  in  early  life  is  more  curved  in  the  anterior  direc- 
tion, and  is,  in  fact,  normally  in  a  state  of  anteflexion.  Sappey  holds 
that  this  is  not  necessarily  the  case,  but  that  the  amount  of  anterior 
curvature  depends  on  the  emptiness  or  fulness  to  the  bladder,  on  which 
the  uterus,  as  it  were,  moulds  itself  in  the  unimpregnated  state.  It  is 
believed  also  that  the  body  of  the  uterus  is  very  generally  twisted  some- 
what obliquely,  so  that  its  interior  surface  looks  a  little  toward  the  right 
side,  this  probably  depending  on  the  presence  and  frequent  distension  of 
the  rectum  in  the  left  side  of  the  pelvis.  The  anterior  surface  of  the 
uterus  is  convex,  and  is  covered  in  three-fourths  of  its  extent  by  the 
peritoneum,  which  is  intimately  adherent  to  it.  Below  the  reflexion  of 
the  membrane  it  is  loosely  connected  by  cellular  tissue  to  the  bladder, 
so  that  any  downward  displacement  of  the  uterus  drags  the  bladder 
along  with  it.  The  posterior  surface  is  also  convex,  jput  more  distinct- 
ly so  than  the  anterior,  as  may  be  observed  in  looHng  at  a  transverse 
section  of  the  organ  (Fig.  19).     It  is  also  covered  by  peritoneum,  the 


Fitr        19 


O'*-'*-'^*-*./ - 


Transverse  Section  of  Uterus 


reflexion  of  which  on  the  rectum  forms  the  cavity  known  as  Douglas's 
pouch.  The  fundus  is  the  upper  extremitv  of  the  uterus,  lying  above 
the  points  of  entry  by  the  Fallopian  tubes.  Itis  only  slightlyjwnded 
in  the  virgin,  but  becomes  more  decidedly  and  permanently  rounded  in 
the  wonran  who_ha.s  borni;[[chi]dren. 

lU  /Surfaces. — Until  the  period  of  puberty  the  uterus  remains  small  I 
and  undeveloped  (Fig.  20) ;  after  that  time  it  reaches  the  adult  size,  at 
which  it  remains  until  menstruation  ceases,  when  it  again  atrophies.  If  i 
the  woman  has  borne  children  it  always  remains  larger  than  in  the  nul- 
lipara. In  the  virgin  adult  the  uterus  measures  2^  inches  from  the 
orifl(;e  to  the  fundus,  rather  more  than  half  being  taken  up  by  the 
cervix.  Its  greatest  breadth  is  opposite  the  insertion  of  the  Fallopian 
tubes;  its  greatest,  thickness,  about  11  or  12  lines,  opposite  the  centre 
of  its  body.  Its  average  weight  is  about^9  or  10  drachms.  Independ- 
ently of  pregnancy,  the  uterus  is  subjccst  to  great  alterations  of  size 
toward  the  menstrual  period,  when,  on  account  of  the  congestion  then 
present,  it  enlarges,  sometimes,  it  is  said,  c()nsi(leral)ly.  This  fact  should 
be  borne  in  mind,  as  this  [)eriodi(;al  swelling  might  be  taken  for  an  early 
pregnancy. 


2. 


58 


ORGANS  CONCERNED  IN  PARTURITION. 


V!1 


Regional  Divisions. — For  the  purpose  of  description  the  uterus  is  con- 
veniently divided  into  the  fundus,  with  its  rounded  upper  extremity, 
situated  between  the  insertions  of  the  Fallopian  tubes ;  the  body,  which 
is  bounded  above  by  the  insertions  of  the  Fallopian  tubes  and  below 
by  the  upper  extremity  of  the  cervix,  and  which  is  the  part  chiefly  con- 


FlG, 


uterus  and  Appendages  in  an  Infant.     (After  Farre. 


cerned  in  the  reception  and  gro^^i:h  of  the  ovum ;  and  the  mruc,  which 
projects  into  the  vagina,  and  dilates  during  labor  to  give  passage  to  the 
child.  The  cervix  is  conical  in  shape,  measuring  11  to  12  lines  trans- 
versely at  the  base,  and  6  or  7  in  the  antero-posterior  direction ;  while 
at  the  apex  it  measures.  7  to  8  transversely,  and  5  antero-posteriorly. 
It  projects  about  4  lines  into  the  canal  of  the  vagina,  the  remainder 
of  the  cervix  being  placed  above  the  reflexion  of  the  vaginal  mucous 
membrane.  It  varies  much  in  foi^m  in  the  virgin  and  nulliparous 
married  woman  and  in  the  woman  ^x\\o  has  borne  children ;  and  the 
differences  are  of  importance  in  the  diagnosis  of  pregnancy  and  uterine 
disease.  In  the  virgin  it  is  regularly  ]jyramidal  iii..£lmx)e.  At  its  lower 
extremity  is  the  opening  of  the  external  os  uteri,  forming  a  small  trans- 
verse fissure,  sometimes  difficult  to  feel,  and  generally  described  as  giving 
a  sensation  to  the  examining  finger  like  the  extremity  of  the  cartilage  at 
the  tip  of  the  nose.  It  is  bounded  by  two  lips,  the  anterior  of  which  is 
apparently  larger  on  account  of  the  position  of  the  uterus.  The  surface 
of  the  cervix  and  the  borders  of  the  os  are  very  smooth  and  regular. 

Changes  after  Childbirth. — In  women  who  have  borne  children  these 
parts  become  considerably  altered.  The  cervix  is  no  longer  conical,  but 
is  irregular  in  form  and  shortened.  The  lips  of  the  os  uteri  become 
fissured  and  lobulated,  on  account  of  partial  lacerations  \vBich  have 
occurred  during  labor.  The  os  is  larger  and  more  irregular  in  outline, 
and  is  sometimes  sufficiently  patulous  to  admit  the  tip  of  the  finger.  In 
old  age  the  cervix  atrophies,  and  after  the  change  of  life  it  not  uncom- 


THE  FEMALE  GENERATIVE  ORGANS. 


59 


monly  entirely  disappears,  so  that  the  orifice  of  the  os  uteri  is  on  a  level 
with  the  roof  of  the  vagina. 

Internal  Surface  of  the  Uterus. — The  internal  surface  of  the  uterus 
comprises  the  cavities  of  the  body  and  cervix — the  former  being  rather 
less  than  the  latter  in  length  in  virgins,  but  about  equal  in  women  who 
have  borne  children — separated  from  each  other  by  a  constriction  form-, 
ing  the  upper  boundary  of  the  cervical  canal.  The^avity  of  the  body 
is_jtnaiigular  in  shape,  the  base  of  the  triangle  being  Jornied_  by  a  line 
joiiimg  the  openIngsl)f  the  Fallopian  tubes,  its  apex  by  the  upper  orifice 
of  the'cervix,  oFTnternal  os,  as  it~is  sonietimes  called.  In  the  virgin 
its  boundaries  are  somewhat  convex,  projecting  inward.  After  child- 
bearing  they  become  straight  or  slightly  concave.  The  opposing  surfaces 
of  the  cavity  are  always  in  contact  in  the  healthy  state,  or  are  only  sep- 
arated from  each  other  by  a  small  quantity  of  mucus. 

Cavity  of  the  Cervix. — The  cavity  of  the  cervix  is  spindle-^aped  or 
fusiform,  narrower  above  and  below  at  the  internal  and  external  os 
uteri,  and  somewhat  dilated  between  these  two  points.     It  is  flattened 


Fjg.  21. 


Portion  of  Interior  of  Cervix.    (Enlarged  nine  diameters.)    (After  Tyler  Smith  and  Hassall.) 


fr<jm  Ijefore  backward,  and  its  opposing  surfaces  also  lie  in  contact,  but 
not  so  closely  as  those  of  the  body.  On  the  mucous  lining  of  the  ,, 
anterior  and  po.sterior  surfaces  is  a  prominent  perpendicular  ridge,  with 
a  lesser  one  at  each  side,  from  which  transverse  ridges  proceed  at  more 
or  less  acute  angles.  They  have  received  the  name  of  the  arbor  vitce. 
Acf!ording  to  Guyon,  the  ])cr}x;ndi(!u]ar  ridges  are  not  exactly  opposite, 
so  that  they  fit  into  each  otli(!r,  and  serve  more  com])letcly  to  fill  up  the 
cavity  of  the  cervix,  especially  toward  tlu;  internal  os  (l^^ig.  21).     The 


u-^ 


60 


OBGANS  CONCERNED  IN  PARTURITION. 


Fig.  22. 


arbor  vitse  is  most  distinct  in  the  virgin,  and  atrophies  considerably 
after  childbearing. 

The  snperior  extremity  of  the  cervical  canal  forms  a  narrow  isthmns 
separating  it  from  the  cavity  of  the  body,  and  measuring  about  fths  of 
an  inch  in  diameter.  Like  the  external  os,  it  contracts  after  the  cessa- 
tion of  menstruation,  and  in  old  age  sometimes  becomes  entirely 
obliterated. 

iStmcture__of,Jh£^_J^^iis. — The  uterus  is  composed  of  three  principal 
structures — the  peritoneal,  muscular,  and  mucous  coats.  The  perito- 
neum forms  an  investment  to  the  greater  part  of  the  organ,  extending 
downward  iiijront  to  the  level_of_tlie  os  internum,  and  behind  to  the 

top  of  the  vagina,  from  which  points 
it  j-S  reflect ed_upj}'ard  on  the  bladder 
aijdrectum_respectively.  At  the  sides 
the  peritoneal  investment  is  not  so 
extensive,  for  a  little  below  the  level 
of  the  Fallopian  tubes  the  peritoneal 
folds  separate  from  each  other,  form- 
ing the  broad  ligaments  (to  be  after- 
ward  described);  here  it  is  that  the 
vessels  and  nerves  supplying  the 
uterus  gain  access  to  it.  At  the 
upper  part  of  the  organ  the  peri- 
toneum is  so  closely  adherent  to  the  muscular  tissue  that  it  cannot 
be  separated  from  it ;  below,  the  connection  is  more  loose.  The  mass 
of  the  uterine  tissiie^Jjoth  in  the  body_and  cervix,  consists  of  unstriped 
muscular  fibres,  firmly  united  together  by  nucleated  connective  ^tissue 
ancL_elastic~fibres.  ^he  muscular  fibre-cells  are  large  and  fusiform, 
with  very  attenuated  extremities,  generally  containing  in  their  centre 
a  distinct  nucleus.  These^  cells,  as  well  as  theirjiuclei,  become^greatly 
enlarged  during  pregnancy  (Fig.  23) ;  according  to  Strieker,  this  is  only 

Fig.  23. 


Muscular  Fibres  of  Unimpregnated  Uterus. 

(After  Farre.) 

a.  Fibres  united  by  connective  tissue. 

6.  Separate  fibres  and  elementary  corpuscles. 


Developed  Muscular  Fibres  from  the  Gravid  Uterus.    (After  Waguer.) 

the  case  with  the  muscular  fibres  which  play  an  important  part  in  the 
expulsion  of  the  fostus,  those  of  the  outermost  and  innermost  layers  not 
sharing  in  the  increase  of  size.^  In  addition  to  these  developed  fibres 
there  are,  especially  near  the  mucous  coat,  a  number  of  round  elementary 
corpuscles,  which  are  believed  by  Dr.  Farre  ^  to  be  the  elementary  form 
of  the  muscular  fibres,  and  which  he  has  traced  in  various  intermediate 

^  Comparafive  Bktology,  vol.  iii.  Syd.  Soc.  Trans.,  p.  477. 
^  The  Uterus  and  its  Appemlof/es,  p.  632. 


THE  FEMALE  GENERATIVE   GROANS.  61 

states  of  development.  Dr.  John  Williams^  believes  that  a  great  part 
of  the  muscular  tissue  of  the  uterus,  rather  more  indeed  than  three- 
fourths  of  its  thickness,  is  an  integral  part  of  the  mucous  membrane, 
analogous  to  the  muscularis  mucosae  of  the  mucous  membrane  of  the 
alimentary  canal.  This  he  describes  as  being  separated  from  the  rest-  of 
the  muscular  tissue  by  a  layer  of  rather  loose  connective  tissue,  contain- 
ing numerous  vessels.  In  early  foetal  life,  and  in  the  uteri  of  some  of 
the  lower  animals,  this  appearance  is  very  distinct ;  in  the  adult  female 
uterus,  however,  it  cannot  be  readily  made  out. 

Arrangement  of  the  Muscular  Fibres. — On  examining  the  uterine 
tissue  in  an  unimpregnated  condition  no  definite  arrangement  of  its 
muscular  fibres  can  be  made  out,  and  the  whole  seem  blended  in  inex- 
tricable confusion.  By  observation  of  their  relations  when  hypertro- 
phied  during  pregnancy,  Helie^  has  shown  that  they  may,  speaking  , 
roughly,  be  divided  into  three  layers — an  external ;  a  middle,  chiefly 
longitudinal ;  and  an  internal,  chiefly  circular.  Into  tlie  details  of  their  | 
distribution,  as  described  by  him,  it  is  needless  to  enter  at  length. 
Briefly,  however,  he  describes  the  external  layer  as  arising  posteriorly 
at  the  junction  of  the  body  and  cervix,  and  spreading  upward  and  over 
the  fundus.  From  this  are  derived  the  muscular  fibres  found  in  the 
broad  and  round  ligaments,  and  more  particularly  described  by  Rouget. 
The  middle  layer  is  made  up  of  strong  fasciculi,  which  run  upAvarcl,  but 
decussate  and  unite  with  each  other  in  a  remarkable  manner,  so  that 
those  which  are  at  first  superficial  become  most  deeply  seated,  and  vice 
versa.  The  muscular  fasciculi  which  form  this  coat  curve  in  a  circular 
manner  round  the  large  veins,  so  as  to  form  a  species  of  muscular  canal 
through  which  they  run.  This  arrangement  is  of  peculiar  importance, 
as  it  affords  a  satisfactory  explanation  of  the  mechanism  by  which 
hemorrhage  after  delivery  is  prevented.  The  internal  layer  is  mainly 
composed  of  circular  rings  of  muscular  fibres,  beginning  round  the 
openings  of  the  Fallopian  tubes,  and  forming  wider  and  wider  circles 
which  eventually  touch  and  interlace  with  each  other.  They  surround 
the  internal  os,  to  which  they  form  a  kind  of  sphincter.  In  addition  to 
these  circular  fibres  on  the  internal  uterine  surface,  both  anteriorly  and 
posteriorly,  there  is  a  well-marked  triangular  layer  of  longitudinal 
fibres,  the  base  being  above  and  the  apex  below,  which  sends  muscular 
fasciculi  into  the  mucous  membrane. 

Its  Mucous  Membrane. — The  anatomy  of  the  lining  membrane  of  the 
uterus  has  been  the  subject  of  considerable  discussion.  Its  existence  has 
been  denied  by  many  autliorities,  most  recently  by  Snow  Beck,^  who 
maintains  that  it  is  in  no  sense  a  mucous  membrane,  but  only  a  softened 
portion  of  true  uterine  tissue.  It  is,  however,  ])rettv  generally_adm.ittcd', 
by  the  best  authorities  that  it  is  essentially  a  nnicQiisLJUimibxaue,  differ- 
ing from  otliers  only  in  being  more  closely  adherent  to  the  subjacent 
structures  in  consequence  of  not  possessing  any  definite  connective-tissue 
framework. 

It  is  a  pale  pink  membrane  of  considerable  thickness,  most  marked  at 

'  "On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,"  ObKlei.  Jovrn.,  1875. 
^  Recherches  sur  la  iJisposition  des  Fibrea  nmscvlairex  de  I'  Uterus,  Paris,  1 8G9. 
'  Obst.  Trans.,  vol.  xiii.  p.  294. 


62 


ORGANS  CONCERNED  IN  PARTURITION. 


the  centre  of  the  body,  where  it  forms  from  one-eighth  to  one-fourth  of 
the  thickness  of  the  whole  uterine  walls.     At  the  internal  os  uteri  it 


Fui.  -24. 


I 


J1 


^ 


■"isSi 


•■iM 


Fig.  25. 


Lining  Membrane  of  Uterus,  showing  Network  of  Capillarieti  and  Oriflces  of  Uterine  Glands. 

(After  Farre.) 
From  the  bod}'.  From  orifice  of  Fallopian  tube. 

terminates  by  a  distinct  border,  which  separates  it  from  the  mucous 

membrane  lining  the  cervical  cavity. 

TJie^JJfncularGJands. — On  the  surface  of  the  mucous  membrane  may 

be  observed  amuTtlKide  of  little  openings,  about  ^^-g-th  of  a  line  in  ^vidth 

(Fig.  24).  These  are  the  orifices  of  the  utric- 
ular glands,  which  are  found  in  immense  num- 
bers all  over  the  cavity  of  the  uterus,  and  very 
.  closely  agglomerated  together.  They  are  little 
cul-de-sacs,  narrower  at  their  mouths  than  in 
their  length,  the  blind  extremities  of  which  are 
found  in  the  subjacent  tissues  (Fig.  26).  Wil- 
liams describes  them  as  running  obliquely  to- 
ward the  surface  at  the  lower  third  of  the  cav- 
ity, perpendicularly  at  its  middle,  while  toward 
the  fundus  they  are  at  first  perpendicular,  and 
then  oblique  in  their  course  (Fig.  25).  By 
others  they  are  described  as  being  often  twisted 
and  corkscrew-like.  One  or  more  may  unite  to 
form  a  common  orifice,  several  of  which  may 
open  together  in  little  pits  or  depressions  on 
the  surface  of  the  mucous  membrane.  These 
glands  are  composed  of  structureless  mem- 
brane lined  with  epithelium,  the  precise  cha- 
racter of  which  is  doubtful.  By  some  it  is  de- 
scribed as  columnar,  by  others  tessellated,  and 
by  some  again  as  ciliated.  The  most  generally 
received  opinion  is  that  it  is  columnar,  but 
not  ciliated  ;  tlierein  difierino'  from  the  epithe- 
lium covering  the  surface  of  the  membrane, 
which  is  undoubtedly  ciliated,  the  movements 
of  tlie  cilia  being  from  within  outward.     Wil- 

The  Course  of  the  Glands  in  the  liams,  liowcver,  has  observed   cilia   in  active 

fully-developed  JIucous    Mem-  '         ,  ,,  ,  -ji     t  t    • 

brane  of  the  Uterus— viz.  just  movement  ou  the  couimnar  epitnelmm  nnmo; 

pS-'lAftlr  wiiiia^ntf "''  ^^^^  ^^^^^'^^^  «"t^  ^Iso  statcs  that  at  the  deep^- 
seated  extremities  of  the  glands,  which  pene- 
trate between  the  muscular  fibres  for  some  distance,  the  columnar  epi- 


THE  FEMALE  GENERATIVE  ORGANS. 


63 


thelium  is  replaced  by  rounded  cells.  The  capillaries  of  the  mucous 
membrane  run  down  between  the  tubes,  forming  a  lacework  on  their 
surfaces  and  round  their  orifices.  No  true  papillae  exist  in  the  mem- 
brane lining  the  uterine  cavity.  The  mucous  membrane  of  the  uterus 
is  peculiar  in  being  always  in  a  state  of  change  and  alteration,  being 
thrown  oif  at  each  menstrual  period  in  the  form  of  debris  in  conse- 
quence of  fatty  degeneration  of  its  structures,  and  re-formed  afresh 
by  proliferation  of  the  cells  of  the  muscular  and  connective  tissues, 
probably  from  below  upward,  the  new  membrane  commencing  at  the 
internal  os.     Hence   its   appearance   and    structure   vary   considerably 

Fig.  26. 


Vertical  Section  through  the  Mucous  Membrane  of  the  Human  Uterus.    (After  Turner.) 
e.  Columnar  epithelium ;  the  Cilia  are  uot  represented.    </  g.   Utricular  glands,    ct.  ct.  luterglandular  con- 
nective tissue,    v.v.  Blood-vessels,    m.m.  Muscularis  mucosae  (^'J".) 

according  to  the  time  at  which  it  is  examined.     The  subject,  however, 
will  be  more  particularly  studied  in  connection  with  menstruation. 

3huiouH  Memhrane  of  the  Cervix. — The  mucous  membrane  of  the  cer-  \  i 
vix  i.s  much  tliicker  aiicl  moreTransparcnt  than  that  of  the  body  of  the  , 
uterus,  from  which  it  also  differs  in  certain  structural  peculiarities.  The 
general  arrangcsments  of  its  folds  and  surface  have  already  been 
described.  The  lower  half  of  the  membrane  lining  the  cavity  of  the 
cervix,  and  the  whole  of  that  covering  its  external  or  vaginal  portion, 
are  (;losely  set  with  a  large  number  of  minute  filiform  or  clavate  papillae 
(Fig.  27).  Their  structure  is  similar  to  that  of  the  mucous  membrane 
itself,  of  which  they  seem  to  })e  merely  elevations.  They  cadi  contain  a 
v'ascular  ]oo[)  (I^^ig.  28),  and  they  are  believed  by  Kilian  and  Favw  to 
1)0  inuinly  concerned  in  giving  sensibility  to  this  part  of  the  generative 


64 


ORGANS  CONCERNED  IN  PARTURITION. 


tract.     All  over  the  interior  of  the  cervix,  j^oth  on  the  ridges  of  the 
mucous  membrane  and  between  their  folds,  are  a  very  large  number  of 


Fig.  27. 


Villi  of  Os  Uteri  stripped  of  Epitlielium.    (After  Tyler  Smith  and  Hassall.) 

mucous   follicles,   consisting,  of  a  structureless   membrane  lined  with 
Lcylindrical  epithelium  and    intimately  united  with  connective  tissue. 

Fig.  28. 


Villi  of  Uterus  cohered  with  Pavement  Epithelium,  and  containing  Looped  Vessels. 
(After  Tyler  Smith  and  Hassall.) 


THE  FEMALE  GENERATIVE   ORGANS.  65 

They  cease  at  the  external  orifice  of  the  cervix,  and  they  secrete  the 
thick,  tenacious,  and  alkaUne  mucus  which  is  generally  found  filling  the 
cervical  cavity.  The  transparent  follicles,  known  as  the  '^  ovula 
Nabothii,''  w^hich  are  sometimes  found  in  considerable  numbers  in  the 
cavity  of  the  cervix,  consist  of  mucous  follicles,  the  mouths  of  which 
have  become  obstructed  and  their  canals  distended  by  mucous  secretion. 
The  lower  third  of  the  cervical  canal,  as  well  as  the  exterior  of  the 
cervix,  is  covered  with  pavement  epithelium ;  while  on  its  upper  portion 
is  found  a  columnar  and  ciliated  epithelium  similar  to  that  lining  the 
uterine  cavity. 

Bandl^  describes  the  cervical  mucous  membrance  as  extending  much 
higher  in  the  virgin  than  in  women  who  have  borne  children,  being 
traceable  in  the  former  nearly  to  the  middle  of  the  body  of  the  uterus. 
During  the  first  pregnancy  he  believes  that  the  upper  portion  of  the 
cervix  is  taken  up  into  the  body  of  the  uterus,  its  mucous  membrane 
never  regaining  the  arrangement  peculiar  to  that  of  the  cervical  canal. 

Vesseh^a[_JheUteriis. — The  arteries  of  the  uterus  are  derived  from  the 
intCTualillacanH'n'om  ^^  ovarian.  They  enter  the  uterus  between  the 
folds  of  the  broad  ligaiuents^  and,"  penetrating  its  muscular  coat,  anas- 
tomose freely  with  each  other  and  with  the  corresponding  vessels  of  the 
opposite  side.  Their  walls  are  thick  and  well  developed,  and  they  are 
remarkable  for  their  very  tortuous  course,  forming  spiral  curves,  espe- 
cially in  the  upper  part  of  the  uterus.  They  end  in  minute  capillaries 
which  form  the  fine  meshes  surrounding  the  glands,  and  in  the  cervix 
give  oif  the  loops  entering  the  papillae.  Beneath  the  uterine  mucous 
membrane  these  capillaries  form  a  plexus,  terminating  in  veins  without 
valves,  which  unite  with  each  other  to  form  the  large  veins  traversing 
the  substance  of  the  uterus,  known  during  pregnancy  as  the  uterine 
sinuses,  the  walls  of  which  are  closely  adherent  to  the  uterine  tissues. 
These  veins,  freely  anastomosing  with  each  other,  pass  outward  to  the 
folds  of  the  broad  ligaments,  where  they  unite  to  form,  with  the  ovarian 
and  vaginal  veins,  a  large  and  well-developed  vejious  network,  known 
as  the  pampimfgrm  plexus. 

ThelA^nj)Im^^  Uterus. — The  lymphatics  of  the  uterus  are 

large'anHwelTTIevelopecr,  ancTtliey  have  recently,  and  with  much  prob- 
ability, been  supposed  to  play  an  important  part  in  the  production  of 
certain  puerperal  diseases.  A  more  minute  knowledge  than  we  at  pres-" 
ent  possess  of  their  course  and  distribution  will  probably  throw  much 
light  on  their  influence  in  this  respect.  According  to  the  researches  of 
Leopold,^  who  has  studied  their  minute  anatomy  carefully,  they  originate 
in  lymph-spaces  between  the  fine  bundles  of  connective  tissue  forming 
the  l^sis  of  the  mucous  lining  of  the  uterus.  Here  they  are  in  intimate 
contact  witli  the  utricular  glands  and  the  ultimate  ramifications  of  the 
uterine  l>lood-vessels.  As  they  pass  into  tlie  nmscular  tissue  tlicy  be- 
come gradually  narrowed  into  lymph-vessels  and  sjjaces,  which  have 
a  very  com])licated  arrangement,  and  which  eventually  unite  togetlier  in 
the  external  muscular  layer,  especially  on  the  sides  of  the  uterus,  to 
form  large  canals  whi(;h  probably  have  valves.  Inmiediately  under  this 
])eriton('al   cov(-'ring  these  lymph-vessels  foi-m  a  large;  and  t^hai'acteristic 

'  ArrJi.f.  rjyn.,  V,.  xiv.  S.  2:57.  =  Il'i'l.,  15(1.  vi.  Heft  i. 


66 


ORGANS  CONCERNED  IN  PARTURITION. 


network  covering;  the  anterior  and  posterior  surfaces  of  the  uterus,  and 
present,  in  various  parts  of  their  coiu'se,  lar<i;e  ampullse.  They  then 
spread  over  the  Fallopian  tubes.  The  lymphatics  of  the  body  of  the 
uterus  unite  with  the  lumbar  glands,  those  of  the  cervix  with  the  pel- 
vic glands. 

The  JSferves  of  the  Uterus. — The  distribution  and  arrangement  of  the 
nerves  of  the  uterus  have  been  the  subject  of  much  controversy.  They 
are  derived  mainly  from  the  ovarian  and  hypogastric  plexuses,  inoscu- 
lating  freely  with  each  other  between  the  folds  of  the  broad  ligament, 
from  which  they  enter  the  muscular  tissue  of  the  uterus,  generally,  but 
not  invariably,  following  the  course  of  the  arteries.  They  are  chiefly ' 
derived  froin_the  sympathetic,  but^  as  the  livpogastric  plexusjs  connected 
with_the_sacral  nerves,  it  is  i^rpbable  that  some  fibresJroni_the  cerebro- 
spmal  systenrare^clistributed  t-o_tlie  cervix.  It  is  now  generally  admit- 
ted that  nervous  filaments  are  distributed  to  tlie_cajrvix,  even  as  far  as 
the  external_os,  although  then*  existence  in  this  situation  has  been  denied 
by  Jobert  and  other  writers.  The  ultimate  distribution  of  the  nerves 
is  not  yet  made  out.  Polle*  describes  a  nerve-filament  as  entering  the 
papillae  of  the  cervical  mucous  membrane  along  with  the  capillary  loop, 
and  Frankenhauser  says  the  nerve-fibres  surround  the  nmscles  of  the 
uterus  in  the  form  of  plexuses  and  terminate  in  the  nuclei  of  the  muscle- 
cells. 

Anomalies  of  the  Uterus. — Various  abnormal  conditions  of  the  uterus 
and  vagina  are  occasionally  met  with,  which  it  is  necessary  to  mention, 
as  they  may  have  an  important  practical  bearing  on  parturition.  The 
most  frequent  of  these  is  the  existence  of  a  double,  or  partially  double. 

Fig.  29. 


Bifid  Uterus.     (After  Farre.) 

uterus  (Fig.  29),  similar  to  that  found  normally  in  many  of  the  lower 
animals.  This  abnormality  is  explained  by  the  development  of  the 
organ  during  fetal  life.  Tlie  uterus  is  formed  out  of  structures  existing 
only  in  early  foetal  life,  knoM'n  as  the  AVolffian  bodies.  These  consist 
of  a  number  of  tubes,  situated  on  either  side  of  the  vertebral  column, 
and  opening  externally  into  an  excretory  duct.  Along  their  external 
border  a  hollow  canal  is  formed,  termed  the  canal  of  Miiller,  whicli,  like 
the  excretory  ducts,  proceeds  to  the  common  cloaca  of  the  digestive  and 
urinary  organs,  which  then  exists.     The   canal  of  Miiller  unites  with 


THE  FEMALE  GENERATIVE  ORGANS.  67 

its  fellow  of  the  opposite  side  to  form  the  uterus  and  Fallopian  tubes  in 
the  female,  and  subsequently  the  central  partition  at  their  point  of  junc- 
tion disappears.  If,  however,  the  progress  of  development  be  in  any 
way  checked,  the  central  partition  may  remain.  Then  we  have  pro- 
duced either  a  complete  double  uterus  or  the  uterus  bicornis,  which  is 
bifid  at  its  upper  extremity  only ;  or  a  double  vagina,  each  leading  to  a  j 
separate  uterus. 

Pregnancy  in  Cases  of  Bifid  Uterus. — If  pregnancy  occur  in  any  of 
these  anomalous  uteri — and  many  such  cases  are  recorded — serious 
troubles  may  follow.  It  may  happen  that  one  horn  of  the  double  uterus 
is  not  sufficiently  large  to  admit  of  pregnancy  going  on  to  term,  and 
rupture  may  occur.  It  is  supposed  that  some  cases,  presumed  to  be 
tubal  gestation,  were  really  thus  explicable.  Impregnation  may  also 
occur  in  the  two  cornua  at  different  times,  leading  to  superfoetation.  It 
is,  however,  quite  possible  that  impregnation  may  occur  in  one  horn  of 
a  bifid  uterus,  and  labor  be  completed  without  anything  unusual  being 
observed.  A  remarkable  case  of  this  sort  has  been  recorded  by  Dr.  Ross 
of  Brighton,'  in  which  a  patient  miscarried  of  twins  on  July  16,  1870, 
and  on  October  31,  fifteen  weeks  later,  was  delivered  of  a  healthy 
child.  Careful  examination  showed  the  existence  of  a  complete  double 
uterus,  each  side  of  which  had  been  impregnated.  Curiously  enough, 
this  patient  had  formerly  given  birth  to  six  living  children  at  term, 
nothing  remarkable  having  been  observed  in  her  labors.  It  can  only 
rarely  happen  that,  under  such  circumstances,  so  favorable  a  result  will 
follow,  and  more  or  less  difficulty  and  danger  may  generally  be  expected. 
Occasionally  the  vagina  only  is  double,  the  uterus  being  single.  Dr. 
Matthews  Duncan  has  recorded  some  cases  of  this  kincP  in  which  the 
vaginal  septum  formed  an  obstacle  to  the  birth  of  the  child,  and  required 
division. 

Lj/mrnenis_of  the  Uterus. — The  various  folds  of  peritoneum  which 
invesrtlieliterus  serve  to  maintain  it  in  position,  and  they  are  described 
as  its  ligaments.  They  are  the_broad^  the  vesico-uterine.  and  sacro- 
uterine ligaments ;  the  round  ligani£nts  are  not  peritoneal  folds  like  the 
others. 

[Within  a  few  years  we  have  had  no  less  than  five  reports  of  cases  of 
labor  in  New  York  and  Philadelphia  in  which  it  was  claimed  that  tubal 
fetal  cvsts  had  discharged  their  contents  through  the  uterus  and  vagina. 
This  is  certainly  not  in  accordance  with  what  is  usually  taught  and 
believed  in  regard  to  the  termination  of  Fallopian  or  interstitial  preg- 
nancies. The  illustration  here  introduced  is  in  evidence  that  a  uterus 
may  be  duplex  and  still  bear  the  outward  form  of  a  single  organ.  Cases 
of  this  type  have  Ijeen  distinctly  recognized  during  life  by  Drs.  Baer  and 
Drysdale  of  Philadelphia ;  and  the  ])atient  of  tlic  fi)rnier  bore  twins, 
whose  i)lacenta3  were  discharged  separately  and  at  an  interval  of  a 
quarter  of  an  hour.  Two  of  the  reports  ah'cady  I'eferred  to  are  illus- 
trated by  drawings  representing  a  normal  uterus  and  a  dilated  Fallopian 
tube.  How  such  a  cyst  is  to  discharge  its  contents  other  than  by  the  usual 
way  of  bursting  into  the  pelvic  cavity  I  cannot  compi-chcnd,  ])articularly 
when  w(!  consider  that  in  what  is  called  interstitial  j)regiian(y  tlic  thickest 

'  Lunci't,  August,  1871.  ^  Research  en  in  OljfilctricK,  ]>.  -l-ll!. 


68 


ORGANS  CONCEHyEI)  IN  PARTUBTTION. 


part  of  the  cyst-wall  is  next  to  the  uterine  cavity,  and  that  rupture 
takes  place  on  the  remote  side.  AVhere  the  uterus  has  but  one  cornu, 
or  where  one  cornu  is  in  a  rudimentary  state,  and  pregnancy  occurs,  we 
may  fall  into  the  error  of  su])posing  that  it  is  of  the  Fallopian  tube. 
Such  a  cornu  may  be  emptied  jx^'i'  '^'iu>^  naturcde,s,  but  the  usual  terminus 
is  by  a  rupture  of  the  sac.  Dr.  Sanger  of  Leipzig  calls  this  form 
"  gynatretic. "  pregnancy,  and  has  collected  21  cases  which  ended  fatally 
in  the  first  six  months  by  rupture,  and  3  in  which  a  Uthopcedion  formed, 
one  of  which  was  successfully  operated  upon  by  Koeberle.[^]  The  impreg- 
nated cornu  has  been  remt)ved,  successfully  in  tA^'o  cases  under  Salin  of 
Stockholm  and  Sanger,  respectively,  and  unsuccessfully  under  Litzmann 
of  Kiel.  Sanger  believes  it  possible  to  distinguish  during  life  a  Fallo- 
pian pregnancy  from  one  of  a  rudimentary  cornu,  but  this  is  not  the 

Fig.  30. 


Partitioned  Uterus.    (Kussmaul.) 

general  opinion,  as  even  after  death  certain  anatomical  points  must  be 
relied  upon.  We  must  note  where  the  round  ligament  is  given  off,  it 
being  between  the  cyst  and  the  uterus  in  a  Fallopian  pregnancy,  and  at 
the  distal  side  of  an  impregnated  cornu.  It  is  to  be  ht)ped  that  the  five 
cases  of  New  York  and  Philadclj)hia  under  dispute  may  some  day  be 
examined  by  autopsy,  and  the  true  character  of  the  pregnancies  deter- 
mined. If  a  Fallojiian  foetal  cyst  can  discharge  itself  into  the  uterus, 
as  claimed,  it  is  strange  that  an  impregnated  rudimentary  cornu  almost 
universally  fails  to  do  so,  but  ends  fatally  by  rupture. — Ed.] 

The_^roa(l^jj(/< vmn if.s. — The  broad  ligaments  extend  from  either  side 
of  the  uterus,^vnere  their  lamina?  are  separated  from  each  other,  trans- 
versely across  to  the  pelvic  wall,  and  thus  divide  the  cavity  of  the  pelvis 
['  Trans.  Inlernational  Med.  Conc/ress  of  Copenhagen,  Aug.  16,  1884.] 


THE  FEMALE  GENERATIVE   ORGANS. 


69 


into  two  parts ;  the  anterior  containing  the  bladder,  the  posterior  the 
rectum.  Their  upper  borders  are  divided  into  three  subsidiary  folds, 
the  anterior  of  which  contains  the  round  ligament,  the  middle  the  Jlal- 
lopian  tube,  and  thejjosterior  the  ovary.  The  arrangement  has  received 
the  name  of  the  ala  vespertilioms,  from  its  fancied  resemblance  to  a  bat's 
wing.  Between  the  folds  of  the  broad  ligaments  are  found  the  uterine 
vessels  and  nerves,  and  a  certain  amount  of  loose  cellular  tissue  con- 


FlG. 


Adult  Parovarium,  Ovary,  and  Fallopian  Tube.    (After  Kobelt.) 

tinuous  with  the  pelvic  fasciae.  Here  is  situated  that  peculiar  structure 
called  the  organ  of  Rosenmiiller,  or  th.Q  parovarium  (Fig.  31),  which  is  the 
remains  of  the  Wolffian  body,  and  corresponds  to  the  epididymus  in  the 
male.  This  may  best  be  seen  in  young  subjects  by  holding  up  the  broad 
ligaments  and  looking  through  them  by  transmitted  light ;  but  it  exists  at 
all  ages.  It  consists  of  several  tubes  (eight  or  ten  according  to  Farre, 
eighteen  or  twenty  according  to  Bankes  ^),  which  are  tortuous  in  their 
course.  They  are  arranged  in  a  pyramidal  form,  the  base  of  the  pyra- 
mid being  toward  the  Fallopian  tube,  its  apex  being  lost  on  the  surface 
of  the  ovary.  They  are  formed  of  fibrous  tissue,  and  lined  with  pave- 
ment epithelium.  They  have  no  excretory  duct  or  communication  with 
eitlier  the  uterus  or^vary,  and  their  function,  if  they  have  any,  is  un- 
known. 

MuHGidar  Fibres  behveen  its  Fojch. — A  number  of  muscular  fibres  are 
also  found  in  this  situation,  lying  between  the  meshes  of  the  connective 
tissue.  They  have  been  particularly  studied  by  Rouget,  who  describes 
tliem  as  interlacing  with  each  other,  and  forming  an  open  network  con- 
tinuous with  the  muscular  tissues  of  the  uterus  (Fig.  32).  They  are 
(livisible  into  two  layers,  the  cinterior  of  wliich  is  continuous  with  the 
nniscular  fil)res  of  the;  anterior  surface  of  tiic  uterus,  and  goes  to  form 
]>art  of  the  round  ligament;  the  jMjsterior  arises  from  th(!  posterior  wall 
of  the  uterus,  and  proceeds  transversely  outward  to  become  attached  to 
the  sacTcviliac  synchondrosis.  A  continuous  mus(;ular  enveh^pe  is  thus 
formed,  which  surrounds  tlio  whole  of  the  uterus.  Fallopian  tubes,  and 

'  Bankes,  On  iMn  WolJJiau.  BodieK. 


7(1 


ORGANS  CONCERNED   IN  PARTURITION. 


ovaries.  Its  fuiietioii  is  not  yet  thoroughly  established.  It  is  supposed 
to  have  the  effect  of  retracting  the  stretched  folds  of  peritoneum  after 
delivery,  and  more  especially  of  bringing  the  entire  generative  organs 
into  harmonious  action  during  menstruation  and  the  sexual  orgasm ;  in 
this  way  explaining,  as  we  shall  subsequently  see,  the  mechanism  by 
which  the  fimbriated  extremity  of  the  Fallopian  tube  grasps  the  ovarv 
prior  to  the  rupture  of  a  Graafian  follicle. 

JJi(:^,lojm(l^LJ(l(nncut.s. — The  round  ligaments  are  essentially  muscular 
in  structure.  They  extend  from  the  upper  border  of  the  uterus,  with 
the  fibres  of  which  their  muscular  fibres  are  continuous,  transversely  and 
then  obliquely  downward,  until  they  reach  the  inguinal  rings,  where 
theyjjlend^with  the^llular  tissue.     In  the  first  part  of  their  course  the 


Posterior  View  of  Muscular  and  ^  ascular  Arrangements.     (After  Rouget.) 

1,  2,  3.  Vaginal,  cci'vical,  and  uterint'  pli'Xuses.  4.  Arteries  of  body  of  ntcrus.  5.  Arteries  s\\\\- 
plying  ovary.  Mnsmlnr  f<tscii-iili :  G,  7.  Klines  attaclicd  to  vagina,  synipliysis  jniliis,  ami  sacro-iliae  joint. 
8.  Sliiscular  fasciculi  from  uterus  and  brcjad  ligaments.  'J,  111,  11,  VI.  Fasciculi  attached  to  o^■al•y  and  Fal- 
lopian tubes. 


muscular  fibres  are  solely  of  the  un.striped  variety,  but  soon  they  receive 
striped  fibres  from  the  transversalis  muscles  and  the  columns  of  the 
inguinal  ring,  which  surround  and  cover  the  unstriped  muscular  tissue. 
In  addition  to  these  structures  they  contain  elastic  and  connective  tissue 
and  arterial^'enous,  and  nervous  branches  ;  the  former  from  the  iliac  or 
crenia.-^tcnc  arteries,  the  lattei'  from  tlie  genito-crural  ner3"e.  According 
to  Mr.  Eainey,  the  princi2)al  function  of  tlie.se  ligaments  is  to  draw  the 


THE  FEMALE  GENERATIVE  ORGANS.  71 

uterus  toward  the  symphysis  pubis  during  sexual  intercourse,  and  thus 
to  favor  the  ascent  of  the  semen. 

The  Vesico-uterine  Lk/aments. — The  vesico-uterine  ligaments  are  two 
folds  of  peritoneum  passiiigliTfront  from  the  lower  part  of  the  body  of 
the  uterus  to  the  fundus  of  the  bladder. 

Th£Uter<>-sac)xd^  Ligaments. — The  utero-sacral  ligaments  consist  of 
folds"'orperrtoneunrof'  a  crescentic  form,  with  their  concavities  looking 
inward :  they  start  from  the  slower  part  of  the  posterior  surface  of  the 
uterus,  and  curve  backward  to  be  attachedjotheihird  and  fourth  sacral 
\^te1bra3.  Within  their  folds  exist  bundles  of  muscular  fibres,  continu- 
ous  with  those  of  the  uterus,  as  well  as  connective  tissue,  vessels,  and 
nerves.  The  experiments  of  Savage,  as  well  as  of  other  anatomists,  show 
that  these  ligaments  have  an  important  influence  in  preventing  downward 
displacement  of  the  womb. 

Alterations  during  Pregnancy. — During  pregnancy  all  these  ligaments 
become  greatly  stretched  and_uufolded,  rising  out  of  the  pelvic  cavity 
and  accommodating  themselves  to  the  increased  size  of  the  gravid  uterus ; 
and  the}^  again  contract  to  their  natural  size,  possibly  through  the  agency 
of  the  muscular  fibres  contained  within  them,  after  delivery  has  taken 
place. 

TA£^_^FMomcm  — The  Fallopian  tubes,  the  homologues  of  the 

vas^dSCTeimarnTtliemale,  are  structures  of  great  physiological  interest. 
They  serve  the  douWe_2urppse  of  conveying  the  semen  to  the  ovary  and 
of  carrying  the  ovule  to  the  uterus.  From  the  latter  function  they  may 
be  looked  on  as  the  excretory  ducts  of  the  ovaries ;  but,  unlike  other 
excretory  ducts,  they  are  movable,  so  that  they  may  apply  themselves 
to  the  part  of  the  ovaries  from  which  the  ovule  is  to  come  ;  and  so  great 
is  their  mobility  that  there  is  reason  to  believe  that  a  Fallopian  tube 
may  even  grasp  the  ovary  of  the  opposite  side.  Each  tube  proceeds 
from  the  upi^er  angle  of  the  uterus  at  firstjbransyersely  outward,  and 
then  do\vnward,  backward,  and  inward,,  so  as~to  reachthe  neighborhood 
of  the  ovary.  In  the  first  part  of  its  course  it  is  straight ;  afterward  it 
becomes  flcMious  and  twisted  on  itself  It  is  contained  in  the  upper 
part  of  the  broad  ligament,  where  it  may  be  felt  as  a  hard  cord.  It 
commences  at  the  uterus  by  a  narrow  opening,  admitting  only  the  pas- 
.sage  of  a  bristle,  known  as  the  ostium  uterinum.  As  it  passes  through  the 
muscular  walls  of  the  uterus  the  tube  takes  a  somewhat  curved  course, 
and  opens  into  the  uterine  cavity  by  a  dilated  aperture.  From  its 
uterine  attachment  the  tube  expands  gradually  until  it  terminates  in  its 
trumpet-shaped  extremity;  just  before  its  distal  end,  however,  it  again 
contracts  slightly.  The  ovarian  end  of  the  tube  is  surrounded  by  a 
number  of  remarkable  fringe-like  processes.  These  consist  of  longi- 
tudinal membran(jus  fimbritie,  surrounding  the  a]:>erture  of  tlie  tube,  like 
the  tentacles  of  a  polyp,  varying  considerably  in  number  and  size,  and 
having  their  edg(!s  (;ut  and  sulxlivided.  On  their  iiuicr  surfa<!e  ai-e  found 
b(;t]i  transverse  and  longitudinal  folds  of  mucous  mcjinbrane,  continuous 
with  tliose  lining  the  tube  itself  (Fig.  33).  One  of  these  fimbrijaJs 
alwaysjarger  and  more  (levelo])ed  than  the  rest,  and  is  indirectly  united 
to  th(!  surfac(!  of  the  ovary  hy_ii  ih\d  of  ])erjtoneum  ])ro(;eeding  from  its 
external  suiik(!e.     Its  tnid(!r  siirfiute  is  grooved  so  as  to  form  a  channel, 


72 


OBGANS  CONCERNED   IN  PARTURITION. 


open  below.  The  function  ol'  thi.s  fringe-like  structure  is  to  grasp  the 
ovary  during  the  menstrual  nisus ;  and  the  fimbria  which  is  attached  to 
the  ovary  would  seem  to  guide  the  tentacles  to  the  ovary  which  thev  are 
intended  to  seize.  One  or  more  supplementary  series  of  fimbriie  some- 
times exist,  which  have  an  aperture  of  connnunication  with  the  canal  of 
the  Fallopian  tube  beyond  its  ovarian  extremity.  His  has  recently 
shown  that  the  fimbriated  extremity  of  the  tube,  after  running  over  the 

Fig.  33. 


Fallopian  Tube  laid  open.    (After  Richard.) 
",  h.  Uterine  portion  of  tube,    c,  d.  Plicte  of  mucous   membrane,    e.  Tubo-ovarian  ligaments  and  fringes. 

/.  Ovary.    </.  Kound  ligaments. 

upper  part  of  the  ovary,  turns  down  along  its  free  border ;  so  that  its 
aperture  lies  below  it,  ready  to  receive  the  ovule  when  expelled  from  the 
Graafian  follicle.' 

Their  Stmciure.-^-The  tubes  themselves  consist  of  peritoneal,  muscu- 
lar, and  mucous  coats.  The  peritoneum  surrounds  the  tube  for  three- 
fourths  of  its  calibre,  and  comes  into  contact  with  the  mucous  lining  at 
its  fimbriated  extremity,  the  only  instance  in  the  body  where  such  a 
jimction_occurs.  The  muscular  coat  is  principally  composed  of  circular 
fibres,  with  a  few  longitudinal  fibres  interspersed.  Its  muscular  charac- 
ter has  been  doubted  by  Robin  and  Richard,  but  Farre  had  no  difficulty 
in  demonstrating  the  existence  of  muscular  fibres,  both  in  the  human 
female  and  many  of  the  lower  animals.  According  to  Robin,  the  mus- 
cular tissue  of  the  Fallopian  tubes  is  entirely  distinct  from  that  of  the 
uterus,  from  which  he  describes  it  as  being  separated  by  a  distinct  cellu- 
lar septum.  The  inucou.s  Iming  is  thrown  jntoji  number  of  renijirkable 
lono-Jtudinal  folds,  each  of  which  contains  a  dense  and  vascular  fibrous 
septum,  with  small  muscular  fibres,  and  is  covered  witli— CQlimmar  and 
eijiated_epiljieliuni.  The  apposition  of  these  produces  a  series  of  minute 
capillary  tubes,  along  which  the  ovules  are  propelled,  the  action  of  the 
cilia,  which  is  toward  the  uterus,  apparently  favoring  their  progress. 

TheOmnes. — The  ovaries  are  the  bodies  in  which  the  ovules  are 

^  Kis,  Archil' fur  Anat.  mid  Phys.,  1881. 


THE  FEMALE  GENERATIVE  ORGANS. 


73 


formed,  and  from  which  they  are  expelled,  and  the  clianges  going  on  in 
them  in  connection  with  the  process  of  ovulation,  during  the  whole 
period  between  the  establishment  of  puberty  and  the  cessation  of  men- 
struation, have  an  enormous  influence  in  the  female  economy.  Normally, 
1;he  ovaries  are  two  in  number ;  in  some  exceptional  cases  a  supple- 
mentary ovary  has  been  discovered ;  or  they  may  be  entirely  absent. 
Tlieylire  placed  in  the  posterior  folds  of  the  broad  ligament,  usually 
below  ihe.  brim  of  the  pelvis,  behind  the  Fallopian  tubes,  the_lefLin 
fron^of  the  rectum,  the  right  in  front  of  some  coils  of  the  small  intes- 
tine. Their  situation  varies,  however,  very  much  under  different  circum- 
stances, so  that  they  can  scarcely  be  said  to  have  a  fixed  and  normal 
position ;  most  probably,  however,  as  has  been  recently  shown  by  His,^ 
they  are  normally  placed  close  below  the  brim  of  the  pelvis,  with  their 
long  diameters  almost  vertical,  and  immediately  above  the  aperture  of 
the  distal  extremity  of  the  Fallopian  tubes.  In  pregnancy  they  rise 
into  the  abdominal  cavity  with  the  enlarging  uterus ;  and  in  certain  con- 
ditions  they  are  dislocated  downward  into  Douglas's  space,  where  they 
may  be  felt  through  the  vagina  as  rounded  and  very  tender  bodies. 

Their  Connections. — The  folds  of  the  broad  ligament,  between  which 
the  ovaries  are  placed,  form  for  them  a Jdnd^of  loose_mesentery.  Each 
of  them  is  united  to  the  upper  angle  of  the  uterus  by  a  special  ligament 
called  the  utero-ovarian.  This  is  a  rounded  band  of  organic  muscular 
fibres,  about  an  inch  in  length,  continuous  with  the  superficial  muscular 
fibres  of  the  posterior  wall  of  the  uterus,  and  attached  to  the  inner 


Traces  of 


A  A.  Ovary  enlarged  under  menstrual  nisus.     b.  Kipe  follicle  projecting  on  its  surface,     n 

previously-ruptured  follicles. 

extremity  of  the  ovary.  It  is  surrounded  by  peritoneum,  and  through 
it  theinuscular  fibres,  whicli  form  an  important  integral  part  in  the 
structure  of  tlie  ovaries,  arc  conveyed  to  them.  The  ovary  is^also 
attaciied_t(>  the  fini])riated  extremity  of  the  Ijillopian  tiibc  in  the  man- 
ner ah-(;ady  described. 

The  oyary  is  of  an  irreiridar  oval  shape  (Fig.  34),  the  uj)])cr  border  i 
being  convex,  tfie  lower — through  which  the  vessels  and  nerves  enter —  ' 


74 


ORGANS  CONCERNED  IN  PARTURITTON. 


being  straiglit.  'J'lie  anltxiur  surfuiie,  like  ihat  of  the  uterus,  is  less 
conxii2LJjjiULlllG_4X)stw^  The  outer  extremity  is  more  rounded  and 

bulbous  than  ihejniieii,  \vliioh_  is  somewhat  poLuted^and  eventually  lost 
in  jts4)njj2er Jjgimient-  By  these  peculiarities  it  is  possible  to  distinguish 
the  left  from  the  right  ovary  after  they  have  been  removed  from  the 
body.  The  ovary  varies  much  in  size  under  different  circumstances. 
On  an  average,  in  adult  life,  it  measures  from  one  to  two  inches  in 
length,  three-quarters  of_an  inch  in_width,  and  about  half  an  inch  in 
thickness.  It^jncreases  greatly  in  size  during  each  menstrual  period — 
a  fact  Avhicli  has  been  demonstrated  in  certain  cases  of  ovarian  hernia, 
in  A\'liicli  the  j)rotruded  ovary  has  been  seen  to  swell  as  menstruation 
commenced ;  also  during_j[)regnancy,  when  it  is  said  to  be  double  its 
usual  size.  Al^iMh£]^ange_j)fMife_jt_atiX2pl^^  and  becomes  rough 
and  wrinkled  on  its  surface.  Before  puberty,  the  surface  of  the  ovary 
is  smooth  and  polished  and  of  a  whitish  color.  After  menstruation 
commences,  its  surface  becomes  scarred  by  the  ruptur£jif_the  r4rnafian 
follicles  (Fig.  34,  a  ((),  each  of  which  leaves  a  little  linear  or  striated 
cicatrix  of  a  brownish  color ;  and  the  older  the  patient  the  greater  is 
the  number  of  these  cicatrices. 

Th^.;iX^  Stimc'turc — The  structure  of  the  ovary  has  been  made  the 
subject  of  many  important  observations.  It  has  an_external  covering 
of  epithelium,  originally  continuous  with  the  peritoneum,  called  by 
some  the  germ-epithelium,  in  consequence  of  the  ovules  being  formed 
from  it  in  early  fcetal  life.  In  the  adult  it  is  separated  from  the  peri- 
toneum at  the  base  of  the  organ  by  a  circular  white  line,  and  it  consists 
of  colunuiar  epithelium,  differing  only  from  the  epithelium  lining_jhe 
Fallopian  tubes,  with  which  it  is  sometimes  continuous  through  the 
attached  fimbria  uniting  the  tube  and  the  ovary,  in_being^destitute^of 
cilia.  Wmmediately  beneath  this  covering  is  the  dense  coat  known  as 
the  tunica  alLuginea,  on  account  of  its  w4iitish  color.  It  consists  of 
short  connective-tissue  fibres,  arranged  in  laminae,  among  which  are 
interspersed  fusiform  muscular  fibres.^  At  the  point  where  the  vessels 
and  nerves  enter  the  ovary  this  membrane  is  raised  into  a  ridge,  which 
is  continiK)i3.a_witli  the  utei'o-ovnrian  lioament,  andjs  called  the  hilmn. 
'The  tunjca  albuginea  is  so  intimately  blended 
I'^'f'-  '^'5.  with  the  stroma  ofrl^  ovary  as  to  be  insep- 

arable on  dissection  ;  it\loes  not,  however,  e_x- 
ist  as  a  distinct  lamina,  but  is  merely  the  ex- 
ternal part-of  the  proper  structure  of  the  ovary, 
in  which  more  dense  connectijiejtissue  is  de- 
veloped than  elsewhere. 

The  Stroma. — On  making  a  long-itudinal  sec- 
tion  of^the  ovary  (Fig.  35),  it  will  be  seen  to 
be  composed  of  two  parts,  the  more  internal  of 
which  is  of  a  reddish  color  from  the  number 
of  vessels  that  ramify  in  it,  and  is  called  the 
mecJuUw'ii  or  vascular  zone ;  while  the  e^cter- 
iiaj^'of  a  whitisir~tinf7reccives  the  name  of 
the  (^r/Zm/^orjx^^  The  former  consists  of  loose 

connective  tissue  niterspersed^witlTelastic,  and  a  considerable  number  of 


Longitudinal  Seotion  of  Adult 
Ovary.    (After  I'arre.) 


M       ^     '  / 


THE  FEMALE  GENERATIVE  ORGANS.  75 

muscular  fibres.  According  to  Rouget^  and  His,^  the  muscular  structure 
forms  the  greater  part  of  the  ovarian  stroma.  The  latter  describes  it  as 
consisting  essentially  of  interwoven  muscular  fibres,  which  he  terms  the 
"  fusiform  tissue,"  and  which  he  believes  to  be  continuous  with  the  muscular 
layers  of  the  ovarian  vessels.  The  former  believes  that  the  muscular 
fasciculi  accompany  the  vessels  in  the  form  of  sheaths,  as  in  erectile 
tissues.  Both  attribute  to  the  muscular  tissues  an  important  influence 
in  the  expulsion  of  the  ovules  and  in  the  rupture  of  the  Graafian  fol- 

FiG.  36. 

'     / 

'■    >-.      .->     --::,    <///     '^>rt    '-B-:-        -■- 

Section  through  the  Cortical  Part  of  the  Ovary, 
e.   Surface  epithelium,     s  s.   Ovarian  stroma.     1  1.  Large-sized  Graafian  follicles.    2  2.   Middle-sized ;    and 
3  3.   Small-sized  Graafian  follicles,     o.   Ovule  within  Graafian  follicle,     v  v.   Blood-vessels  in  the  stroma. 
</.  Cells  of  the  membrana  granulosa.     (After  Turner.) 

licles.  Waldeyer  and  other  writers,  however,  do  not  consider  it  to  be 
so  extensively  developed  as  Rouget  and  His  believe.  The  cortical  sub- 1 
stance  is  the  more  important,  as  that  in  which  the  Graafian  follicles  and  I 
ovules  are  formed.  It  consists  of  interlaced  fibres  of  connective  tissue, 
containing  a  large  number  of  nuclei.  The  muscular  fibres  of  the  medul- 
lary substance  do  not  seem  to  penetrate  into  it  in  the  human  female. 
In  it  are  fi)und  the  Graafian  follicles,  Avhich  exist  in  enormous  numbers 
from  the  earliest  periods  of  life,  and  in  all  stages  of  development  (Fig. 
36.) 

TIie^m(if/m  -Fo/^'c/eg.^r-Accordi ng  to  the  researches  of  Pfliiger, 
Waldeyer,  and  other  German  writers,  the  Graafian  follicles  are  formed 
in  early  foetal  life  by  (cylindrical  inflections  of  the  epithelial,  covering  of 
the  ovary,  which  di])  into  the  substance  of  the  gland.  These  tubular 
filaments  anastomose  witli  each  otlier,  and  in  tliem  are  formed  tlie 
ovules,  which  are  originally  the  epithelial  cells  lining  the  tubes.  Por- 
tions l)Cconi(;  shut  off  from  the  rest  of  the  fihiinents  and  fi>rm  the 
Graafian  fidlicles.  The  ovules,  on  this  view,  are  highly-developed 
epithelial  cells,  originally  derived  from  the  surface  of  the  ovary,  and 

'  Jon.rn/il.  de.  PIi.i/kIo/.,  i.  p.  T?)?.  ^  Schiiltze'.s  Arch.f.  jMikrn/^c.np.  Anal.,  1865. 


76 


ORGANS  CONCERNED  IN  PARTURITION. 


not  developed  in  its  stroma.  These  tnbular  filaments  disappear  shortly 
after  birth,  but  they  have  recently  been  detected  by  Slavyansky  ^  in  the 
ovaries  of  a  woman  thirty  years  of  age.  These  observations  have  been 
modified  by  Dr.  Fonlis.^  He  recognizes  the  origin  of  the  ovules  from 
the  germ-epithelium  covering  the  surface  of  the  ovary,  which  is  itself 
derived  from  the  WolflHan  body.  He  believes  all  the  ovules  to  be 
formed  from  the  germ-epithelium  corpuscles,  which  become  imbedded 
in  the  stroma  of  the  ovary,  by  the  outgrowth  of  processes  of  vascular 
connective  tissue,  fresh  germ-epithelial  corpuscles  being  constantly  pro- 
duced on  the  surface  of  the  organ  up  to  the  age  of  two  and  a  half  years, 
to  take  the  place  of  those  already  imbedded  in  its  stroma.  He  believes 
the  Graafian  follicles  to  be  formed  by  the  growth  of  delicate  processes 
of  connective  tissue  between  and  around  the  ovules,  but  not  from 
tubular  inflections  of  the  epithelium  covering  the  gland,  as  described 
by  Waldeyer  (Fig.  37).  This  view  is  supported  by  the  researches  of 
Balfour,^  who  arrives  at  the  conclusion  that  the  whole  egg-containing 

Fig.  37. 


.r 


\TJ" 


Vertical  Section  through  the  Ovary  of  the  Hmiian  Foetus. 
g  g.  Gerni-ppitlieliuiu,  witli  o  o.  Developiiig:  ovules  in  it.     s  s.   Ovarian  stroma,  containing  c  c  c.    Fusiform 
connective-tissue  cciriiuscles.     v  v.  Capillai'y  blood-vessels.     In  the  centre  of  tlie  tigure  an  involution  of 
the  gcrni-epitlieliiini  is  sliown  ;  and  at  tlie  left  lower  sitle  a  primordial  ovule,  with  the  connective-tissue 
corpuscles  ranging  tlieniselves  round  it.    (After  Foulis.) 

part  of  the  ovary  is  really  the  thickened  germinal  epithelium,  broken 
up  into  a  kind  of  meshwork  by  growths  of  vascular  stroma.  According 
to  this  theory,  Pfluger's  tubular  filaments  are  merely  trabeculse  of 
germinal  epithelium,  modified  cells  of  which  become  developed  into 
ovules. 

_  The  greater  portion  of  the  Graafian  follicles  are  only  visible  with  the 
high  ])owers  of  the  microscope,  but  those  which  are  approaching  matur- 
ity are  distinctly  to  be  seen  by  the  naked  eye.  The  quantity  of  these 
follicles  is  iuimense.  Foulis  estimates  that  at  birth  each  huiiian  ovary 
contains  not  less  than  80,000.  jS^o  fresh  follicles  appear  to  be  formed 
after  birth,  aud  as  development  goes  on  some  only  grow,  and,  by  pres- 

^  Annulex  de  Ch/iu'c,  Feb.,  1S71. 

2  Prnreech'iu/s  nf  Ihe  B<u/(tl  Soc.  of  Erlhib.,  Aiiril,  1875,  and  Journ.  of  Anat.  and  Phys., 
vol.  xiii.,  1879. 

^  F.  M.  Balfour,  "Structure  and  Development  of  Vertebrate  Ovary,"  Quarterly 
Journal  of  Microscopical  Science,  vol.  xviii.,  1878. 


THE  FEMALE  GENERATIVE   ORGANS. 


77 


sure  on  the  others,  destroy  them.  Of  those  that  grow,  of  course  only 
a  few  ever  reach  maturity ;  they  are  scattered  through  the  substance  of 
the  ovary,  some  developing-  in  the_  stroma,  others  on  the  surface  of  the 
orggn^wWp  tlipy  eventually  burst,  and  are  discharged  into  the_Falk>- 
j)ian_tube. 

Stmdurrjil^^  Follicle. — A  ripe  Graafian  follicle  has  an 

"^external  investing  membrane7Fiir38),  which  is  generally  described  as 

Fig.  38. 


1.  Ovum. 


Diagrammatic  Section  of  Graafian  Follicle. 

2.  lilenibrana  granulosa.     3.  External   membrane  of  Graafian  follicle.    4.  Its  vessels. 

rian  stroma.     6.  Cavity  of  Graafian  follicle.     7.  External  covering  of  ovary. 


consisting  of  two  distinct  layers — the  external,  or  tunjca-fibrosa,  highly 
vascular,  and  formed  of  connective  tissue ;  the  internal,  or  tunica__fiw- 
pria,  composed  of  young  connective  tissue,  containing  a  large  number 
of  fusiform  or  stellate  cells  and  numerous  oil-globules.  These  layers, 
hoAvever.  ap]3ear  to  be  essentially  formed  of  condensed  ovarian  stroma. 
-^•Within  this  capsule  is  the  epitheliaHining  called  the  menibrana  aranu- 
hsa^  consisting  of  stratified  columnar  epithelial  cells,  which,  according 
foFoiilis,  are  originally  formed  from  the  nuclei  of  the  fibro-nuclear  tis- 
sue of  the  stroma  of  the  ovary.  At  one  part  of  the  circumference  of  the 
ovisac  is  situated  the  ovule,  around  which  the  epithelial  cells  are  con- 
gregated_in  greater  quantity,  cojistituting  the  projection  known  as  the 
dii£Hs  proUqerm.  ^S'The  remainder  of  the  cavity  of  tlie-fiiUiclais  filled 
witli  a  small  (|uantity  of  transparent  fluid,  the  liquo?'  folliculi.  traversed 
by  three  or  four  minute  bands,  the  retinacula"^bf  i^arry,  which  are 
attached  to  the  opposite  walls  of  the  follicular  cavity,  and  apparently 
serve  the  purpose  of  su.spending  the  ovule  and  maintaining  it  in  a  proper 
position.  In  many  young  follicles  this  cavity  does  not  at  first  exist,  the 
follicle  being  entirely  filled  by  the  ovule.  According  to  Waldeyer,  the 
lifjuor  fiilliculi  is  formed  by  the  disintegration  of  the  epithelial  cells, 
the  fluid  thus  produced  collecting,  and  distending  the  interior  of  the 
follicle. 

The  Ovvfe. — The  onile  is  attached  to  some  part  of  the  internal  sur- 
face  of  the  (iraafian  follicle.  It  is  a  rounded  vesicle  about  x-g-pth  of  an 
infli  in  diameter,  and  is  surrounde<l  l)y  a  layer  of  (^olumnai'  cells,  dis- 
tinct from  tho.so  of  the  discus  ])roligerus,  in  which  it  li(!S.  Jt  is  invested 
by  a  transparent  elastic  membrane,  the  zona  pellucida,  or  vitelline  mem  - 


78 


ORGANS  COyCEEXED  IN  PARTURITION. 


brane.  In  most  of  the  lower  aninuils  tlie  zona  pellucida  is  perforated 
by  nnnierons  very  minnte  pores,  only  visible  inuler  the  highest  powers 
of  the  microscope ;  in  others  there  is  a  distinct  aperture  of  a  larger  size, 
the  micropyle,  allowing  the  passage  of  the  spermatozoa  into  the  interior 
of  the  ovule.  It  is  possible  that  similar  apertures  may  exist  in  the 
human  ovule,  but  they  have  not  been  demonstrated.  Within 'the  zona 
pellucida  some  embryologists  describe  a  second  fine  membrane,  the  exist- 
ence of  which  has  been  denied  by  Bischoff.  The_C'avity  of  the  ovule  is 
filled  with  a  viscid  yellow  fluid,  the  yelk,  containing, numerous  granules. 
It  entirely  fills  the  cavity,  to  the' waTlsof  which  it  is  non-adherent.  In 
the  centre  of  the  yelk  in  young,  and  aj_some  ]3ortion  of  its  ]3eripherv_ln 
mature  ovules,  is  situated  the_.r/r///;/;/^//rc>J^?'c/<",  which  is  a  clear  circular 


vesicle,  refracting  light  stronglv,  and  about  -^t\\  of  a 


line  in  diameter. 


It  contains  a  few  granules,  and  a  nucleolus,  or  gerijiiiiaL^pgt,  which  is 
sometimes  double.  '    '       ^" 

From  within  outward,  therefore,  we  find — 

1.  The  germinal  is^ot ;  round  this 

2.  The  germinal  vesicle,  contained  in 

3.  The  yelk,  which  is  surroiuided  by  the 

4.  Zona  pellaekla,  M'ith  its  layers  of  columnar  epithelial  cells. 
These  constitute  the  ovule. 

The  ovule  is  contained  in — 

The  Graafian  follicle,  and  lies  in  that  part  of  its  epithelial  lining 
called  the — 

Discus  2^1'oHgerus,  the  rest  of  the  follicle  being  occupied  by  the  liquor 
folliculi.  Round  these  we  have  the  epithelial  lining  or  membrana 
granulosa,  and  the  external  coat,  consisting  of  the  tunica  propria  and 
the  tunica  fibrosa. 

TJie^^s^els^inxl^Nerves^ of_Jh€__Oyciry. — The  vascular  supply  of  the 
ovary  is  complex.  THitT^tei'ies^^ci^^  at  the  hilnm,  penetrating  the 
stroma  in  a  spiral  curve,  and  are  ultimately  distributed  in  a  rich  capil- 

Fic4.  39. 


Bulb  of  Ovary, 
r.  Uterus,     o.  Ovary  ami  utoin-ov.niiaii  iijianiciit.    r.  Fallopian  tiibn.     1.  T'tnin-nvariaii  vein, 
form  ovariau  plexus.     3.  Coniineuceuieiit  uf  spermatic  vein. 


I'ampini- 


larv  plexus  to  the  follicles.  The  large  veins  unite  freely  with  each 
other,  and  form  a  vascular  and  erectile  plexus,  continuous  with  that  sur- 
ronnding  the  uterus,  called  the  bulb  of  the  ovary  (Fig.  39).  Lymphat- 
ics and  nerves  exist,  but  their  mode  of  termination  is  unknown. 


THE  FEMALE  GENERATIVE  ORGANS.  79 

The  Mavimaril  _Glands. — To  complete  the  consideration  of  the  gener- 
ative organs  of  the  female  we  must  study  the  mammary  glands,  whicli^ 
secrete  the  fluid  destined  to  nourish  the  child.     In  the  human  subject!^ 
they  are  two  in  number,  and  instead  of  being  placed  upon  the  abdomenJ^ 
as  in  most  animals,  they  are  situated  on  either  side  of  the  sternum,  over   -^ 
the  pectorales  majora  muscles,  and  extencHi'om_the_third  to  the  _sixth    ^ 
rib.     This  position  of  the  glands  is  obviously  intended  to  suit  the  erect    ' 
position  of  the  female  in  suckling.     They  are  convex  anteriorly,  and 
flattened  posteriorly  wliere  they  rest  on  the  muscles.    They  vary  greatly 
in  size  in  diflerent  subjects,  chiefly  in  proportion  to  the  amount  of  adi- 
pose tissue  they  contain.     In  man,  and  in  girls  previous  to  puberty, 
they  are   rudimentary   in    structure,   while    in    pregnant    women   they 
increase  greatly  in  size,  the  true  glandular  structures  becoming  much 
hypertrophied.      Anomalies    in    shape    and    position    are    sometimes 
observed.     Supplementary  maramse,  one  or  more  in  number,  situated  on 
the  upper  portion  of  the  raammaj,  are  sometimes  met  with,  identical  in 
structure  with  the  normally  situated  glands ;  or,  more  commonly,  an 
extra  nipple  is  observed  by  the  side  of  the  normal  one.     In  some  races, 
especially  the  African,  the  mammae  are  so  enormously  developed  that 
the  mother  is  able  to  suckle  her  child  over  her  shoulder. 

Their  Structure. — The  skin  covering  the   gland  is  soft  and  supple, 
and  during  pregnancy  often  becomes  covered  with  fine  white  lines,  while 

Fig.  40. 


1.  Galactophorous  ducts.    2.  Lobuli  of  the  mammary  gland. 

large  blue  veins  may  be  observed  coursing  over.  Underneath  it  is  a 
quantity  of  connective  tissue,  containing  a  considerabk  amount  of  fat. 
which  extends  beneath  the  true  glandular  structure!  Tliis  is  com])osed 
of  from  fifteen  to  twenty  lobes,  each  of  which  is  formed  of  a  number_of 
lol>ii]e.s.  The  lobules  are  produced  bv  the  aggregation  of  the  terminal 
acini  in  which  tlie  miTir^sformed.  The  acini  are  minute  culs-de-sac 
opening  into  little  diicts,  Avhich  unite  with  each  otiier  until  they  form  a 
large  duct  for  each  lobule  ;  the  ducts  of  each  lobule  unite  with  each  other 
until  they  end  in  a  still  larocr  duct  common  to  each  of  thejjfteen  or 
twenty  lobes  into_whjcl.i  the  Ldand  is  divided,  and  eventually  open  on 
the  siH^facc  of  the  nipple.  These  terminal  canals  are  known  as  tlio 
(lalado^fihoroiiH  ducts.  (Fig-  40).  They  become  widely  dilated  as  lluy 
a|)i)roach  tha.jilpple,  so  as  toi()rm  rescrvojrs_Jn  which  milk  is  siorcj 
until  it  is  required,  but  when  they  actually,  enter  the  nipple  they  again 


80  ORGANS  CONCERNED  IN  PARTURITION. 

contract.  Sonictinics  they  give  off  lateral  l)ran('hes,  but,  according  to 
Sappev,  they  do  ncjt  anastomose  with  each  other,  as  some  anatomists 
have  described.  These  excretory  ducts  are  composed  of  connective  tis- 
sue, Avith  numerous  elastic  fibres,  on  their  external  surface.  Sappey 
and  Robin  describe  a  layer  of  muscular  fibres,  chiefly  developed  near  their 
terminal  extremities.  They  are  lined  VN^thcoluraim^ 
tinuous  with  that  in  the^acini ;  and  iFis^  by  the  distensionof  its  cells  with 
fatty  matter,  and  their  subsequent  bursting,  that  the  milk  is  formed. 

TJie  NipjAe. — The  nipj^le  is  the  conical  i^rojection  at  the  summit  of 
the  mamma,  and  it  varies  in  size  in  different  women.  Not  very  unfre- 
quently,  from  the  continuous  pressure  to  which  it  has  been  subjected  by 
the  flress,  it  is  so  depressed  below  the  surface  of  the  skin  asjo  prevent 
lactation.  It  is  generally  larger  in  married  than  in  single  women,  and 
increases  in  size  during  pregnancy.  Its_  surface  is  covered  with  iiumerous 
papillae,  giving  it  a  rugous  aspect,  and  at  their  bases  the  orifices  of  the 
lactiferous  ducts  open.  Here  are  also  the  openings  of  numerous  sebaceous 
follicles,  which  secrete  an  unctuous  material  supposed  to  protect  and 
soften  the  integument  during  lactation.  Beneath  the  skin  are  muscular 
fibres,  mixed  with  connective  and  elastic  tissues,  vessels,  nerves,  and 
lymphatics.  When  the  nipple  is  irritated  it  contracts  and  hardens,  and 
by  some  this  is  attributed  to  its  erectile  properties.  The  vascularity, 
however,  is  not  great,  and  it  contains  no  true  erectile  tissue  ;  the  harden- 
ing is,  therefore,  due  to  muscularcoiitraction.  Surrounding  the  nip])le 
is_the  areoki,  of  a  pink  color  in  virgnis,  becoming  dark  I'rom  the  develop- 
ment  of  pigment-cells  during  pregnancy,  and  always  remaining  some- 
what dark  after  childbearing.  On  its  surface  are  a  number  of  prominent 
tubercles,  sixteen  to  twenty  in  number,  ^\^'hicll  also  become  largely 
dcA'elopecl  cluring  gestation.  They  are  supposed  by  some  to  secrete  milk, 
and  to  open  into  the  lactiferous  tubes ;  most  probably  they  are  composed 
of  sebaceous  glands  only.  Beneath  the  areola  is  a  circular  band  of  mus- 
cular fibres,  the  object  of  which  is  to  compress^  the  lactiferous  tubes 
which  run  through  it,  and  thus  to  favor  the  expulsion  of  their  contents. 
\  The  mammae  receive  their  blood  from  the  internal  mammary  and  inter- 


cqsta]_arteries,  and  they  are  richly  supplied  with  lymphatic  vessels,  wliich 
open  into  the  axillary  glands.  The  nerves  are  derived  from  the  inter- 
costal and  thoracic  branches^ofJiieJjnichiaL-pifixus^ 

The  secretion  of  milk  in  women  who  are  nursing  is  accompanied  by 
a  peculiar  sensaliion,  as  if  milk  were  rushing  into  the  breast,  called  the 
"  draught,"  which  is  excited  by  the  efforts  of  the  child  to  suck  and  by 
various  other  causes.  The  sym]iathetic  relations  between  the  man^inae 
and  the  uterus  arc  very  well  marked,  as  is  shown  in  the  unimpregnated 
state  by  the  fact  of  the  frequent  occurrence  of  sympathetic  pains_in_the 
breastin  connection  with  various  uterine  diseases,  and  after  delivery  by 
the  well-known  fact  that  suctTorT  produces  reflex  contraction  of  the 
uterus,  and  even  severe~al!er-pains. 


Plate    III. 


Fig   I. 

/,  rcce-MlPv)    ruptured   and    Btood)?  Sra^ifiaia 
foffiofe/ .  iMSt   de-ve^fopinp"  ivifo  a  Corpus  fute^um 


Corpus    Eufeuw    ten  days    afteA- vnensfruatior 


■C-~     ''■^. 


Fig.  ;i. 

wfi'cc^   ftfls   rie-oev   rupfure-d, 


Fig  4-. 

Corpus  Put&wvv\'  of  ^re.g'nanGy 


ILLUSTRATIONS    OF  THE  CORPUS  LUTEUM,  C AFTER  DALT ON.) 

9.9tlorflS.fil«i.?ffiiC. 


OVULATION  AND  MENSTRUATION.  81 


CHAPTER    III. 
OVULATION  AND  MENSTKUATION. 

Functions  of  the  Ovary. — The  main  function  of  the  ovary  is  to  supply 
the  female  generative  element,  and  to  expel  it,  when  ready  for  impregna- 
tion, into  the  Fallopian  tube,  along  which  it  passes  into  the  uterus. 
This  process  takes  place  spontaneously  in  all  viviparous  animals,  and 
without  the  assistance  of  the  male.  In  the  lower  animals  this  periodical 
discharge  receives  the  name  of  the  oestrum  or  rut,  at  which  time  only 
the  female  is  capable  of  impregnation  and  admits  the  approach  of  the 
male.  In  the  human  female  the  periodical  discharge  of  the  ovule,  in  all 
probability,  takes  place  in  connection  with  menstruation,  which  may 
therefore  be  considered  to  be  the  analogue  of  the  rut  in  animals.  Between 
each  menstrual  period  Graafian  follicles  undergo  changes  which  prepare 
them  for  rupture  and  the  discharge  of  their  contained  ovules.  After 
rupture  certain  changes  occur  which  have  for  their  object  the  healing  of 
the  rent  in  the  ovarian  tissue  through  which  the  ovule  has  escaped,  and 
the  filling  up  of  the  cavity  in  which  it  was  contained.  This  results  in 
the  formation  of  a  peculiar  body  in  the  substance  of  the  ovary,  called 
the  corpus  luteum,  which  is  essentially  modified  should  pregnancy  occur, 
and  is  of  great  interest  and  importance.  During  the  whole  of  the  child- 
bearing  epoch  the  periodical  maturation  and  rupture  of  the  Graafian  fol- 
licles are  going  on.  If  impregnation  does  not  take  place,  the  ovules  are 
discharged  and  lost ;  if  it  does,  ovulation  is  stopped,  as  a  general  rule, 
during  gestation  and  lactation. 

Theory  of  Menstruation. — This,  broadly  speaking,  is  an  outline  of  the 
modern  theory  of  menstruation,  which  was  first  broached  in  the  year  1821 
by  Dr.  Power,  and  subsequently  elaborated  by  Negrier,  Bischoff,  Racibor- 
ski,  and  many  other  writers.  Although  the  sequence  of  events  here  indi- 
cated may  be  taken  to  be  the  rule,  it  must  be  remembered  that  it  is  one  sub- 
ject to  many  exceptions,  for  undoubtedly  ovulation  may  occur  without  its 
outward  manifestation,  menstruation,  as  in  cases  in  which  impregnation 
takes  place  during  lactation  or  before  menstruation  has  been  established, 
of  which  many  examples  are  recorded.  These  exceptions  have  led  some 
modern  writers  to  deny  the  ovular  theory  of  menstruation,  and  their 
views  will  require  subsequent  consideration. 

In  order  to  understand  the  subject  projjerly  it  will  be  necessary  to 
study  tlie  sequence  of  events  in  detail. 

( linnfjesin  the  Graafian  Follicle. — The  changes  in  the  Graafian  follicle 
w!ii(Tl  are  associated  with  the"  discharge  of  the  ovules  comjM'isc — 1. 
Jfatii ration.  As  the  period  of  ])ul)erty  approaches,  a  certain  number  of 
the  Graafian  follicles,  fifteen  to  twenty  in  number,  increase  in  size,  and 
f'ome  n(!ar  the  surface  of  the  ovary.  Amongst  these  one  becomes  es])eci- 
ally  dcvelojMid,  j)reparatory  to  rupture,  and  upon  it,  fi>r  the  time  being, 
c 


82  ORGANS  CONCERNED  IN  PARTURITION. 

all  the  vital  energy  of  the  ovary  seems  to  be  concentrated.  A  similar 
change  in  one,  sometimes  in  more  than  one,  follicle  takes  place  period- 
ically during  the  whole  of  the  childbearing  epoch,  in  connection  with 
each  menstrual  period,  and  an  examination  of  the  ovary  will  show 
several  follicles  in  different  stages  of  development.  The  maturing  folli- 
cle becomes  gradually  larger,  until  it  forms  a  projection  on  the  surface 
of  the  ovary,  from  five  to  seven  lines  in  breadth,  but  sometimes  even  as 
large  as  a  nut  (Fig.  34).  This  growth  is  due  to  the  distension  of  the 
follicle  by  the  increase  of  its  contained  fluid,  which  causes  it  so  to  press 
upon  the  ovarian  structures  covering  it  that  they  become  thinned,  sep- 
arated from  each  other,  and  partially  absorbed,  until  they  eventually 
readily  lacerate.  The  follicle  also  becomes  greatly  congested,  the  capil- 
laries coursing  over  it  become  increased  in  size  and  loaded  with  blood, 
and,  being  seen  through  the  attenuated  ovarian  tissue,  give  it,  when 
mature,  a  bright-red  color.  At  this  time  some  of  these  distended  capil- 
laries in  its  inner  coat  lacerate,  and  a  certain  quantity  of  blood  escapes 
into  its  cavity.  This  escape  of  blood  takes  place  before  rupture,  and 
seems  to  have  for  its  principal  object  the  increase  of  the  tension  of  the 
follicle,  of  which  it  has  been  termed  the  menstruation.  Pouchet  was  of 
opinion  that  the  blood  collects  behind  the  ovule,  and  carries  it  up  to  the 
surface  of  the  follicle.  2.  Escape  of  the  Ovule.  By  these  menus  the  fol- 
licle is  more  and  more  distended,  until  at  last  it  ruptures  (Plate  III. 
Fig.  1),  either  spontaneously  or,  it  may  be,  under  the  stimulus  of  sexual 
excitement.  Whether  the  laceration  takes  place  during,  before,  or  after 
the  menstrual  discharge  is  not  yet  positively  known ;  from  the  results 
of  post-mortem  examination  in  a  number  of  women  who  died  shortly 
before  or  after  the  period,  Williams  believes  that  the  q\^iles_arej^xpelied 
before  the  monthly  flow  commences.^  In  order  that  the  ovule  may 
escape,  the  laceration  must,  of  couree,  involve  not  only  the  coats  of  the 
Graafian  follicles,  but  also  the  superincumbent  structures. 

Laceration  seems  to  be  aided  by  the  gro^^i;h  of  the  internal  layer  of 
the  follicle,  which  increases  in  thickness  before  rupture,  and  assumes  a 
characteristic  yellow  color  from  the  number  of  oil-globules  it  then  con- 
tains. It  is  also  greatly  facilitated,  if  it  be  not  actually  produced,  by 
the  turgescence  of  the  ovary  at  each  menstrual  period,  and  by  the  con- 
traction of  the  muscular  fibres  in  the  ovarian  stroma.  As  soon  as  the 
rent  in  the  follicular  walls  is  produced,  the  ovule  is  discharged,  sur- 
rounded by  some  of  the  cells  of  the  membrana  granulosa,  and  is  received 
into  the  fimbriated  extremity  of  the  Fallopian  tube,  which  grasps  the 
ovary  over  the  site  of  the  rupture.  By  the  vibratile  cilia  of  its  epithe- 
lial lining  it  is  then  conducted  into  the  canal  of  the  tube,  along  which 
it  is  propelled,  partly  by  ciliary  action  and  partly  by  muscular  contrac- 
tion in  the  walls  of  the  tube. 

Obliteration  of  the  Graafian  Follicle. — After  the  ovule  has  escaped, 
certain  characteristic  changes  occur  in  the  empty  Graafian  follicle,  which 
have  for  their  object  its  cicatrization  and  obliteration.  There  are  great 
differences  in  the  changes  which  occur  when  impregnation  has  followed 
the  escape  of  the  ovule,  and  they  are  then  so  remarkable  that  they  have 
been  considered  certain  signs  of  pregnancy.     They  are,  however,  differ- 

^  Proceedings  of  the  Royal  Society,  1875. 


OVULATION  AND  MENSTRUATION. 


83 


Fig.  41. 


ences  of  degree  rather  than  of  kind.  It  will  be  well;  however,  to  discuss 
them  separately. 

Changes  undergone  by  the  Follicle  when  Impregnation  does  not  Occur. — 
As  soon  as  the  ovule  is  discharged,  the  edges  of  the  rent  through  which 
it  has  escaped  become  agglutinated  by  exudation,  and  the  follicle  shrinks, 
as  is  generally  believed,  by  the  inherent  elasticity  of  its  internal  coat, 
but  according  to  Robin,  who  denies  the  existence  of  this  coat,  from 
compression  by  the  muscular  fibres  of  the  ovarian  stroma.  In  pro- 
portion to  the  contraction  that  takes  place,  the  inner  layer  of  the  fol- 
licle, the  cells  of  which  have  become  greatly  hypertrophied  and  loaded 
with  fat-granules  previous  to  rupture,  is  thrown  into  numerous  folds 
(Plate  III.  Fig.  2).  The  greater  the  amount  of  contraction  the  deeper 
these  folds  become,  giving  to  a  section  of  the  follicle  an  appearance 
similar  to  that  of  the  convolutions  of  the 
brain  (Fig.  41).  Th^se  folds  in  the  human 
subject  are  generally  of  a  bright-yellow 
color,  but  in  some  of  the  mammalia  they 
are  of  a  deep  red.  The  tint  was  formerly 
ascribed  by  Raciborski  to  absorption  of  the 
coloring  matter  of  the  blood-clot  contained 
in  the  follicular  cavity — a  theory  he  has 
more  recently  abandoned  in  favor  of  the 
view  maintained  by  Coste  that  it  is  due  to 
the  inherent  color  of  the  cells  of  the  lining 
membrane  of  the  follicle,  which,  though 
not  well  marked  in  a  single  cell,  becomes 
very  apparent  en  masse.  The  existence  of 
a  contained  blood-clot  is  also  denied  by  the  section  of  ovary,  showing  corpus 

latter    physiologist,     except    as    an    unusual      Luteum  three  weeks  after  Menstru- 
i    .•'  ^    ,.'  .  •'^     -,     ,  -,  .,  ation.    (After  Dalton.) 

pathological    condition ;   and   he   describes 

the  cavity  as  containing  a  gelatinous  and  plastic  fluid,  which  becomes 
absorbed  as  contraction  advances.  The  more  recent  researches  of  Dal- 
ton,^ however,  show  the  existence  of  a  central  blood-clot  in  the  cavity 
of  the  follicle,  and  he  considers  its  occasional  absence  to  be  connected 
with  disturbance  or  cessation  of  the  menstrual  function.  The  folds  into 
w^hich  the  membrane  has  been  thrown  continue  to  increase  in  size,  from 
the  proliferation  of  their  cells,  until  they  unite  and  become  adherent, 
and  eventually  fill  the  follicular  cavity.  By  the  time  that  another 
Graafian  follicle  is  matured  and  ready  for  rupture  the  diminution  has 
advanced  considerably,  and  the  empty  ovisac  is  reduced  to  a  very  small 
size.  The  cavity  is  now  nearly  obliterated,  the  yellow  color  of_tlie_ con- 
volutions is  altered. into  a  whitijibjtint,  and  on  section  the  corpus  luteum 
has  the  appearance  of  a  compact  white  stellate  cicatrix,  which  generally 
disappears  in  less  than  forty  days  from  the  pfidLod-of-Oipiure.  The  tis- 
sue oi'  the  ovary  at  the  site  of  laceration  also  shrinks,  and  tliis,  aided  by 
the  contraction  of  the  fi)llicle,  gives  rise  to  one  of  those  ])ermanent  ])its 
or  depressions  which  mark  the  snrfaceof  the  adult  ov'^ary.  Slavyansky  ^ 
has  shown  that  only  a  few  of  the  immense  number  of  Graafian  follicles 

'  "Report  on  the  C'ori)iis  Luteum,"  American  Gynac.  Trans.,  vol.  ii.,  1878. 
'^  Archiv.  (le  Phya.,  March,  1874. 


84 


OEGANS  CONCERNED  IN  PARTURITION. 


undergo  these  alterations.  The  greater  proportion  of  them  seem  never 
to  discharge  their  ovules,  but,  after  increasing  in  size,  undergo  retro- 
gressive changes  exactly  similar  in  their  nature,  but  to  a  much  less 
extent,  to  those  which  result  in  the  formation  of  a  corpus  luteum.  The 
sites  of  these  may  afterward  be  seen  as  minute  strise  in  the  substance  of 
the  ovary. 

Changes  undergone  by  the  Follicle  when  Impregnation  has  taken  place. 
— Should  pregnancy  occur,  all  the  changes  above  described  take  place ; 
but,  inasmuch  as  the  ovary  partakes  of  the  stimulus  to  w^hich  all  the 
generative  organs  are  then  subjected,  they  are  much  more  marked  and 

j  apparent  (Plate  III.  Pig.  4).    Instead  of  contracting  and  disappearing 

,  in  a  few  weeks,  the  corpus  luteum  continues  to  grow  until  the  third  or 
fourth  month  of  pregnancy ;  the  folds  of  the  inner  layer  of  the  ovisac 

"become  large  and  fleshy  and  permeated  by  numerous  capillaries,  and 
ultimately  become  so  firmly  united  that  the  margins  of  the  convolutions 
thin  and  disappear,  leaving,  only  a  firm  fleshy  yellow  mass,  averaging 
from  1  to  11  inches  in  thickness,  which  surrounds  a  central  cavity,  often 
containmg  a  whitish  fibrillated  structure,  believed  to  be  the  remains  of 
a  central  blood-clot.  This  was  erroneously  supposed  by  Montgomery  to 
be  the  inner  layer  of  the  follicle  itself,  and  he  conceived  the  yellow  sub- 
stance to  be  a  new  formation  between  it  and  the  external  layer,  while 
Robert  Lee  thought  it  was  placed  external  to  both  the  external  and 
internal  layers. 

I  Between  the  third  and  fourth  months  of  pregnancy,  when__tlie_corpus 
luteimi  has_attained  its  maximum  of  development  (Fig.^),  it  forms  a 
firm  projection  on  the  surface  of  the  ovary,  averaging  about  1  inch  in 


Fig.  42. 


Fig.  43. 


Corpus  Luteum  of  the  Fourth  Month  of 
Pregnancy,    (.\fter  Dalton.) 


Corpus  Luteum  of  Prepnancy 
at  Term.    (After  Dalton.) 


length  and  rather  more  than  1  an  inch  in  breadth.  After  this  it  com- 
mences to  atn)i)hv  (Fig.  43),  the  fat-cells  become  absorbed,  and  tlie 
capillaries  disappear.  Cicatrization  is  not  complete  until  from  one  to 
two  months  after  delivery. 

ItsValue  as  a  Sif/n  of  Pregnanci/. — On  account  of  the  marked  appear- 
ance of  the  corpus  luteum  it  was  formerly  considered  to  be  an  infallible 


OVULATION  AND  MENSTRUATION.  85 

sign  of  pregnancy ;  and  it  was  distinguished  from  the  corpus  hiteum  of 
the  non-pregnant  state  by  being  called  a  "  true  "  as  opposed  to  a  "  false  " 
corpus  luteum.  From  what  has  been  said  it  will  be  obvious  that  this 
designation  is  essentially  wrong,  as  the  difference  is  one  of  degree  only. 
Dalton  ^  applies  the  terra  "  false  corpus  luteum  "  to  a  degenerated  con- 
dition sometimes  met  with  in  an  unru])tured  Graafian  follicle  consisti ng 
in  reabsorption  of  its  contents  and  thicKcning  of  itswalls  (Plate  III.  Fig. 
3),  It  differs  from  the  "  true  "  corpus  luteum  inbeing_deeply  seated  in 
the  substance  of  the  ovary,  in  having  no  central  clot,  aiidin  being  uncon- 
nected with  a  cicatrix  on  the  surface  of  the  ovary.  Nor  do  obstetricians 
attach  by  any  means  the  same  importance  as  they  did  formerly  to  the 
presence  of  the  corpus  luteum  as  indicating  impregnation ;  for  even 
when  well  marked,  other  and  more  reliable  signs  of  recent  delivery, 
such  as  enlargement  of  the  uterus,  are  sure  to  be  present,  especially  at 
the  time  when  the  corpus  luteum  has  reached  its  maximum  of  develop- 
ment ;  while  after  delivery  at  term  it  has  no  longer  a  sufficiently  charac- 
teristic appearance  to  be  depended  on. 

Mendruation. — By  the  term  menstruation  (cataraenia,  periods,  etc.)  is 
meant  the  periodical  discharge  of  blood  from  the  uterus  which  occurs, 
in  the  healthy  woman,  every  lunar  month,  except  during  pregnancy  and 
lactation,  when  it  is,  as  a  rule,  suspended.  - 

Period  of  Establislwient. — The  first  appearance  of  menstruation  coin- 
cides with  the  establishment  of  ])uberty,  and  the  physical  changes  that 
accompany  it  indicate  that  the  female  is  capable  of  conception  and  child- 
bearing,  although  exceptional  cases  are  recorded  in  which  pregnancy 
occurred  before  menstruation  had  begun.  In  temperate  climates  it  gen- 
erally commences  between  the  14th  and  16th  years,  the  largest  number 
of  cases  being  met  with  in  the  15th  year.  This  rule  is  subject  to  many_ 
exceptions,  it  being  by  no  means  very  rare  for  menstruation  to  become 
established  as  early  as  the  10th  or  11th  year,  or  to  be  delayed  until  the 
18th  or  20th.  Beyond  these  physiological  limits  a  few  cases  are  from 
time  to  time  met  with  in  which  it  has  begun  in  early  infancy,  or  not 
until  a  comparatively  late  period  of  life. 

Influence  of  Climate,  Race,  _etc. — Various  accidental  circumstances 
have  much  to  do  with  its  establishment.  As_a  rule,  it  occurs  somewhat 
earlier  in  tropical,  and  later  in  VCTy^cold  than  in_teniperate  climates. 
The  influence  of  climate  has  been  unduly  exaggerated.  It  used  to  be 
generally  stated  that  in  the  Arctic  regions  women  did  not  menstruate 
until  they  were  of  mature  age,  and  that  in  the  tropics,  girls  of  10  or  12 
years  of  age  did  so  habitually.  The  researches  of  Robertson  of  Man- 
chester^ first  showed  that  the  generally  received  opinions  were  erroneous; 
and  the  collection  of  a  large  number  of  statistics  has  corroborated  his 
o])iiiion.  There  can  be  no  doubt,  however,  that  a  larger  pro])ortion  of 
girls  menstruate  early  in  warin  climates.  Joulin  found  that  in  tropical 
climates,  out  of  16.35  cases,  the  largest  pro]-)()rtion  began  to  menstruate 
tljetwcen  the  12th  and  l:3th  years;  so  that  tliere  is  an  average  difference 
of  more  than  tAvo  years  between  the  period  of  its  establishment  in  the 
tropics  and   in   temperate  countries.     Harris^  states   that   among   the 

'  Op.  ciL,  p.  64.  ■■'  Edin.  Med.  and  Surf/.  Journ.,  1832. 

^  Amer.  .Jon.rn.  nf  OIjhIpI.,  1871,  li.  I'.  Iljirris  on  early  puljerty. 


80  ORGANS  CONCERNED  IN  PARTURITION. 

Hindoos  1  to  2  per  cent,  menstruate  as  early  as  nine  years  of  age ;  3  to 
4  per  cent,  at  ten ;  8  per  cent,  at  eleven ;  and  25  per  cent,  at  twelve ; 
^dlile  in  London  or  Paris  probably  not  more  than  one  girl  in  1000  or 
1200  does  so  at  nine  years.  The  converse  holds  true  with  regard  to 
cold  climates,  although  we  are  not  in  possession  of  a  sufficient  number 
of  acciniite  statistics  to  draw  very  reliable  conclusions  on  this  point ; 
but  out  of  4715  cases,  including  returns  from  Denmark,  NorAvay  and 
Sweden,  Russia,  and  Labrador,  it  was  found  that  menstruation  was 
established  on  an  average  a  year  later  than  in  more  temperate  countries. 
It  is  probable  that  the  mere  influence  of  temperature  has  much  to  do  in 
producing  these  differences,  but  there  are  other  factors,  the  action  of 
which  must  not  be  overlooked.  Racibor,ski  attributes  considerable 
im])ortance  to  the  effect  of  race ;  and  he  has  quoted  Dr.  Webb  of 
(Calcutta  to  the  effect  that  English  girls  in  India,  although  subjected  to 
the  same  climatic  influence  as  the  Indian  races,  do  not,  as  a  rule,  men- 
struate earlier  than  in  England ;  Avhile  in  Austria  girls  of  the  Magyar 
race  menstruate  considerably  later  than  those  of  German  parentage.^ 
The  surroundings  of  gjrls,  and_their  mannei'  of  education  and  livi ng, 
have  probably  also  a  marked  influence  m  promotmg  or  retarding  its 
establishment.  Thus,  it  will  commence  earlier  in  the  children  of  tlie 
rich,  who  are  likely  to  have  a  highly-developed  nervous  organization, 
and  are  habituated  to  luxurious  living  and  a  premature  stimulation  of 
the  mental  faculties  by  novel-reading,  society,  and  the  like ;  while 
amongst  the  hard-worked  poor,  or  in  girls  brought  up  in  the  country, 
it  is  more  likely  to  begin  later.  Premature  sexual  excitement  is  said 
also  to  favor  its  early  appearance,  and  the  influence  of  this  among  the 
factory-girls  of  Manchester,  who  are  exposed  in  the  course  of  their 
work  to  the  temptations  arising  from  the  promiscuous  mixing  of  the 
sexes,  has  been  pointed  out  by  Dr.  Clay.^ 

\_Precocious  Physical  Womanhood. — Within  a  few  years  the  photo- 
graphic process  has  made  us  familiar  with  the  appearances  of  several 
little  girls  of  four,  five,  and  six  years  of  age  who  were  menstruating 
regularly,  had  large  mammae,  and  pubes  covered  with  hair,  all  natives 
of  our  Northern  States.  In  growth  and  obesity  such  children  are  far 
beyond  their  years  as  a  general  rule,  but  in  mental  development  and 
character  very  child-like.  Lately  I  saw  one  of  six,  who,  although  large, 
broad,  and  full-chested,  and  with  arms  and  thighs  like  a  woman,  Avas 
playing  Avith  a  doll  and  acting  like  a  little  girl  of  her  own  age  ;  another, 
of  five  and  a  half,  was  a  beautiful  miniature  of  a  developing  girl  of  twelve 
or  fifteen  ;  and  a  third,  of  four,  had  breasts  as  large  as  an  orange.  For- 
tunately, the  sexual  passion,  so  general  with  the  precociously-cleveloped 
male  infant,  is  seldom  a  marked  characteristic  in  the  female,  although 
cases  of  precocity  are  nuich  more  frequently  met  M'ith  in  girls.  The 
nubile  period  has  seldom  been  tested  in  these  subjects,  but  occasionally 
in  the  loAver  classes  of  society,  pregnancy  has  occurred  at  a  very  early 
age.  Sue,  in  his  Essais  kistoriques,\^~\  Paris,  1779,  reports  a  case  where, 
the  young  mother  was  eight  years  and  ten  months  old,  the  foetus  being 
mature,  but  dead.     Menstruation  began  at  two  years.     Her  mammae 

^  Op.  cit,  p.  227.  •■'  Brit.  Record  of  Obsiet.  Med.,  vol.  i. 

[=*  Vol.  ii.  p.  344.] 


-S  ^io-  OVULATIQN  AND  MENSTRUATION. 

and  pubes  resembled  those  of  a  girl  of  seventeen.  The  youngest  mother 
in  the  United  States  was  ten  years  and  thirteen  days  old,  four  feet 
seven  inches  in  height,  and  100  pounds  in  weight.  [']  She  commenced 
to  menstruate  at  one  year;  her  child  weighed  7|^  pounds.  The  youngest 
English  mother  was  born  on  August  8, 1871 ;  commenced  to  menstruate 
when  a  year  old,  and  bore  a  child  of  7  pounds  in  weight,  after  a  labor 
of  only  6  hours,  in  March,  1881.  [^]  She  ceased  to  menstruate  on  June 
22,  1880,  and  must  have  become  pregnant  when  eight  years  ten  and  a 
half  months  old.  She  was  nine  years  seven  and  a  half  months  old  when 
her  case  was  reported,  March  24,  1881. 

A  Southern  negress  just  thirteen  years  old  gave  birth  to  a  female 
child  at  maturity,  who  in  turn  became  also  pregnant  at  twelve.  This 
child  menstruated  at  ten  years'  and  nine  months,  and  a  second  child  at 
seven  years  and  nine  months.  If  the  first  daughter  became  a  mother  in 
due  time,  then  the  first-mentioned  negress  must  have  become  a  grand- 
mother before  she  was  twenty-six.  [^] 

A  Spanish  girl  of  Maracaibo  is  reported  by  the  late  Prof.  C.  D. 
Meigs  to  have  given  birth  to  a  child  at  twelve,  and  twins  at  a  second 
birth  before  she  was  fourteen.  A  quadroon  of  Nassau,  New  York,  in 
1822,  performed  the  Csesarean  operation  on  herself  when  in  labor  with 
twins  at  the  age  of  fourteen. — Ed.] 

Changes  occurring  at  Puberty. — The  first  appearance  of  menstruation 
is  accompanied  by  certain  well-marked  changes  in  the  female  system,  on 
the  occurrence  of  which  we  say  that  the  girl  has  arrived  at  the  period 
of  puberty.  The  pubes  becomes  covered  with  hair,  the  breasts  enlarge, 
the  pelvis  assumes  its  fully-developed  form,  and  the  general  contour  of 
the  body  fills  out.  The  mental  qualities  also  alter :  the  girl  becomes 
more  shy  and  retiring,  and  her  whole  bearing  indicates  the  change  that 
has  taken  place.  The  menstrual  discharge  is  not  established  regularly 
at  once.  For  one  or  two  months  there  may  be  only  premonitory  symp- 
toms— a  vague  sense  of  discomfort,  pains  in  the  breasts,  and  a  feeling  of 
weight  and  heat  in  the  back  and  loins.  There  then  may  be  a  discharge 
of  mucus  tinged  with  blood,  or  of  pure  blood,  and  this  may  not  again 
show  itself  for  several  months.  Such  irregularities  are  of  little  con- 
sequence on  the  first  establishment  of  the  flmction,  and  need  give  rise  to 
no  apprehension. 

Period  of  Duration  and  Recurrence. — As  a  rule,  the  discharge  recurs 
every  twenty-eight  days^.  and  with  some  women  with  such  regularity 
thaf  they  can  foretell  its  appearance  almost  to  the  hour.  The  rule  is, 
however,  subject  to  very  great  variations.  It  is  by  no  means  uncom- 
mon, and  strictly  within  the  limits  of  health,  for  it  to  appear  every 
twentieth  day,  or  even  with  less  interval ;  while  in  other  cases  as  much 
as  six  weeks  may  habitually  intervene  between  two  periods.  The  period 
of  recurrence  may  also  vary  in  the  same  subject.  I  am  acquainted  with 
patients  who  sometimes  only  liavc  twenty-eiglit  days,  at  others  as  many 
as  forty-eight  days,  between  their  periods,  witliout  tlieir  health  in  any 
way  suffering.     Joulin  mentions  the  case  of  a  lady  who  only  menstru- 

'  TravHylvnnia  Med.  Journ.,  vol.  vii.  p.  447.] 

-'  Lancd,  April  <),  1881,  p.  fiOl.] 

'  Am.  Journ.  Oh-ilehicn,  vol.  vl.  p.  572,  1873-74.] 


88  ORGANS  CONCERNED  IN  PARTURITION. 

ated  two  or  three  times  in  the  year,  and  whose  sister  had  the  same 
pecnliarity. 

The  duration  of  thej>eriod  varies  in  different  womerr,  and  in  the  same 
woman  at  different  tinier!  IiTthiscountry  its  average  is  four  or^ve 
days^vhile  in  France,  Dubois  and  Brierre  de  Boismont  fix  eight  days  as 
the  most  usual  length.  Some  women  are  only  unwell  for  a  fe\\'  hours, 
while  in  others  the  period  may  last  many  days  beyond  the  average 
without  being  considered  abnormal. 

Quantihi  of  Blood  lost — The  quantity  of  blood  lost  varies  in  different 
women.  Hippocrates  puts  it  at  oxviij,  which,  however,  is  much  too 
high  an  estimate.  Arthur  Farre  thinks  that  from  sijto  .siij  is  the  full 
amount  of  a  healthy  period,  and  that  the  quantity  cannot  habitually 
exceed  this  without  producing  serious  coiistitutional  effects.  Rich  diet, 
luxurious  living,  and  anything  that  unhealthily  stimulates  the  body  and 
mind  will  have  an  injurious  effect  in  increasing  the  flow,  which  is, 
therefore,  less  in  hard-worked  country-women  than  in  the  better  classes 
and  residents  in  towns. 

It  is  more  abundant  in  warm  climates,  and  our  countrywomen  in 
India  habitually  menstruate  over-profusely,  becoming  less  abundantly 
unwell  when  they  return  to  England.  The  same  observation  has  been 
made  with  regard  to  American  women  residing  in  the  Gulf  States,  who 
improve  materially  by  removing  to  the  Lake  States.  Some  w^omen 
appear  to  menstruate  more  in  summer,  than  in  winter.  I  am  acquainted 
with  a  lady  who  spends  the  wdnter  in  St.  Petersburg,  where  her  periods 
last  eight  or  ten  clays,  and  the  summer  in  England,  M'here  they  never 
exceed  four  or  five.  The  difference  is  probably  due  to  the  effect  of  the 
overheated  rooms  in  which  she  lives  in  Russia. 

The  daily  loss  is  not  the  same  during  the  continuance  of  the  period. 
It  generally  is  at^_firstjli&bt?  ai^d  gradually  increases,  so  as  to  be  most 
profuse  on  the  second  or  thirdclay/  ^i^d  as  graduallj_diminishes. 
TowarcT  theTast  days  it  soinetimes  disappears  for  a  few  hours,  and 
then  comes  on  again,  and  is  apt  to  recur  under  any  excitement  or 
'  emotion. 

Qualify  of  Menstrual  Blood. — As  the  menstrual  fluid  escapes  from 
the  uteriisTt  consists  of  pureblood,  and  if  collected  through  the  specu- 
lum it  coagulates.  The  ordinary  menstrual  fluid  docs_not  coagulate 
unless  it  is  excessive  in_  amount.  Various  explanations  of  this  fact 
have  been  given.  IFwas  formerly  supposed  either  to  contain  no  fibrin 
or  an  unusually  small  amount.  Retzius  attributes  its  non-coagulation 
to  the  presence  of  free  lactic  and  phosphoric  acids.  The  true  explana- 
tion was  first  given  by  Mandl,  who  proved  that  eyen_small  quantities 
of  pus  or  mucus  in  blood  were  sufficient  to  Iceepjhe  fibrin  in  solution  ; 
and  mucus  is  always  present  to  greater  or  less  amount  in  the  secretions 
of  the  cervix  and  vagina,  w^hich  mix  with  the  menstrual  blood  in  its 
passage  through  the  genital  tract.  If  the  amount  of  blood  be  excessive, 
however,  the  mucus  present  is  insufficient  in  quantity  to  produce  this 
effect,  and  coagula  are  then  formed. 

I  On  microscopic  examination  the  menstrual  fluid  exhibits  bloocl- 
corpusclcs,  mucous  corpuscles,  and  a  considerable  amount  of  epithelial 
scales,  the  last  being  the  debris  of  the  epithelium  lining  the  uterine 


OVULATION  AND  MENSTRUATION.  89 

cavity.  According  to  Virchow,  the  form  of  the  epithelium  often  proves 
that'  it  comes  from  the  interior  of  the  utricular  glands.  The  color  of 
the  blood  is  at  first  dark,  and  as  the  period  progresses  it  generally 
becomes  lighter  in  tint.  In  women  who  are  in  bad  health  it  is  often 
very  pale.  These  differences  doubtless  depend  upon  the  amount  of 
mucus  mingled  with  it.  The  menstrual  blood  has  always  a  character- 
istic, faint,  and  heavy  odor,  which  is  analogous  to  that  which  is  so 
distinct  in  the  lower  animals  during  the  rut.  Raciborski  mentions  a 
lady  who  was  so  sensitive  to  this  odor  that  she  could  always  tell  to 
a  certainty  when  any  woman  was  menstruating.  It  is  attributed  either 
to  decomposing  mucus  mixed- with  the  blood,  which,  when  partially 
absorbed,  may  cause  the  peculiar  odor  of  the  breath  often  perceptible 
in  menstruating  women,  or  to  the  mixture  with  the  fluid  of  the  seba- 
ceous secretion  from  the  glands  of  the  vulva.  It  probably  gave  rise 
to  the  old  and  prevalent  prejudices  as  to  the  deleterious  properties  of 
menstrual  blood,  which,  it  is  needless  to  say,  are  altogether  without 
foundation. 

Sowrce_of_JkeBlood. — It  is  now  universally  admitted  that  the  source 
of  the  menstrual  blood  is  the  mucous  membrane  lining  the  interior  of 
the  uterus,  for  the  blood  may  be  seen  oozing  through  the  os  uteri  by 
means  of  the  speculum,  and  in  cases  of  prolapsus  uteri,  while  in  cases 
of  inverted  uterus  it  may  be  actually  observed  escaping  from  the  exposed 
mucous  membrane,  and  collecting  in  minute  drops  upon  its  surface. 
During  the  menstrual  nisus  the  whole  mucous  lining  becomes  congested 
to  such  an  extent  that,  in  examining  the  bodies  of  women  who  have  died 
during  menstruation,  it  is  found  to  be  thicker,  larger,  and  thrown  into 
folds,  so  as  to  completely  fill  the  uterine  cavity.  The  capillary  circula- 
tion at  this  time  becomes  very  marked,  and  the  mucous  membrane 
assumes  a  deep-red  hue,  the  network  of  capillaries  surrounding  the  ori- 
fices of  the  utricular  glands  being  especially  distinct.  These  facts  have 
an  unquestionable  connection  with  the  production  of  the  discharge,  but 
there  is  much  difference  of  opinion  as  to  the  precise  mode  in  which  the 
blood  escapes  from  the  vessels.  Coste  believed  that  the  blood  transudes 
through  the  coats  of  the  capillaries  without  any  laceration  of  their  struc- 
ture. Farre  inclines  to  the  hypothesis  that  the  uterine  capillaries  ter- 
minate by  open  mouths,  the  escape  of  blood  through  these,  between  the 
menstrual  periods,  being  prevented  by  muscular  contraction  of  the  ute- 
rine walls.  Pouchet  believed  that  during  each  menstrual  epoch  the 
entire  mucous  membrane  is  broken  down  and  cast  oft*  in  the  form  of 
minute  shreds,  a  fresh  mucous  membrane  being  developed  in  the  inter- 
val between  two  periods.  During  this  process  the  capillary  network 
would  be  laid  bare  and  ruptured,  and  the  escape  of  blood  readily 
accounted  for.  Tyler  Smith,  who  adopted  this  theory,  states  that  he 
has  frcfjuently  seen  the  uterine  mucous  membrane,  in  women  who  have 
died  during  menstruation,  in  a  state  of  dissolution,  with  the  broken  loops 
of  the  capillaries  exposed.  The  phenomena  attending  the  so-called 
membranous  dysmenorrlioea,  in  which  the  mucous  membrane  is  thrown 
off  in  shreds  or  as  a  cast  of  the  uterine  cavity — the  nature  of  which 
was  first  pointed  out  by  Simpson  and  Oldham — have  been  supposed  to 
corroborate  tliis  theory.     This  view  is,  in  the  main,  corroborated  by  the 


A.. 


90  ORGANS  CONCERNED  IN  PARTURITION. 

recent  researches  of  Eujyelmann/  Williams,^  and  others.  Williams  de- 
scribes the  mucous  lining  of  the  uterus  as  undergoing  a  fatty  degenera- 
tion before  each  period,  which  commences  near  the  inner  os,  and  extends 
over  the  whole  mucous  membrane  and  down  to  the  muscular  wall.  This 
seems  to  bring  on  a  certain  amount  of  muscular  contraction,  which  drives 
the  blood  into  the  capillaries  of  the  mucosa,  and  these,  having  become 
degenerated,  readily  rupture,  and  permit  the  escape  of  the  blood.  The 
mucous  membrane  now  rapidly  disintegrates,  and  is  cast  off  in  shreds 
with  the  menstrual  discharge,  in  which  masses  of  epithelial  cells  may 
always  be  detected.  Engelmann,  however,  holds  that  the  fatty  degenera- 
tion is  limited  to  the  superficial  layers,  and  that  a  portion  only  of  the 
epithelial  investment  is  thrown  off.  As  soon  as  the  period  is  over  the 
formation  of  a  new  mucous  membrane  is  begun,  from  proliferation  of 
the  elements  of  the  muscular  coat,  and  at  the  end  of  a  week  the  whole 
uterine  cavity  is  lined  by  a  thin  mucous  membrane.  This  grows  until 
the  advent  of  another  period,  when  the  same  degenerative  changes  occur 
unless  impregnation  has  taken  place,  in  which  case  it  becomes  further 
develojjed  into  the  decidua. 

TJieory^qf  Menstruation. — That  there  is  an  intimate  connection  be- 
tween ovulation  and  menstruation  is  admitted  by  most  physiologists, 
and  it  is  held  by  many  that  the_detennining_cajis^^  is 

the  periodic  maturation  of  the  Grraafian  follicles.  There  is  abundant 
evidence  of  this~comiection,  lor  weTinow  that  when,  at  the  change  of 
life,  the  Graafian  follicles  cease  to  develop,  menstruation  is  arrested ; 
and  when  the  ovaries  are  removed  by  operation,  of  which  there  are  now 
numerous  cases  on  record,  or  when  they  are  congenitally  absent,  men- 
■    \  struation  does  not  generally  take  place.    A  few  cases,  however,  have  been 

;(^  V    '')  observed  in  which  menstruation  continued  after  double  ovariotomy  or 
f/^ ,       the  removal  of  the  ovaries  by  Battey's  operation  ;  and  these  have  been 
,  ^'*"'       used  as  an  argument  by  those  physiologists  who  doubt  the  ovular  theory 
of  menstruation.      Slavyanski  has  particularly  insisted  on  such  cases, 
,  which,  however,  are  probably  susceptible  of  explanation.     It  may  be 

^^  that  the  habit  of  menstruation  may  continue  for  a  time  even  after  the 

nyy  removal  of  the  ovaries ;  and  it  has  not  been  shown  that  menstruation 
has  continued  permanently  after  double  ovariotomy,  although  it  cer- 
tainly has  occasionally,  although  quite  exceptionally,  done  so  for  a  time. 
It  is  possible,  also,  that  in  such  cases  a  small  portion  of  ovarian  tissue 
may  have  been  left  unremoved,  sufficient  to  carry  on  ovulation.  Roberts, 
a  traveller  quoted  by  Depaul  and  Gueniot  in  their  article  on  "  Menstrua- 
tion "  in  the  Dictionnaire  des  Sciences  Medicales,  relates  that  in  certain 
parts  of  Central  Asia  it  is  the  custom  to  remove  both  ovaries  in  young 
girls  who  act  as  guards  to  the  harems.  These  women,  known  qis  "  hed- 
jeras,"  subsequently  assume  much  of  the  virile  type,  and  never  menstru- 
ate. The  same  close  connection  between  ovulation  and  the  rut  of  ani- 
nials  is  observed,  and  supports  the  conclusion  that  the  rut  and  menstru- 
tibn  are  anafogoiis.  The  chief  difference  between  ovulation  in  man  and 
the  lower  animals  is  that  in  the  latter  the  process  is  not  generally  accom- 
panied by  a  sanguineous  flow.     To  this  there  are  exceptions,   for  in 

^  American  Journal  of  Obstetric^,  May,  1875. 

^  "On  the  Structure  of  the  Mucous  Membrane  of  the  Uterus,"  Obst.  Journ.,  1875. 


'0- 


OVULATION  AND  MENSTRUATION.  91 

monkeys  there  is  certainly  a  discharge  analogous  to  menstruation  occur- 
ring at  intervals.  Another  point  of"  distinction  is  that  in  animals  con- 
nection never  takes  place  except  during  the  rut,  and  that  it  is  then  only 
that  the  female  is  capable  of  conception ;  while  in  the  human  race  con- 
ception only  occurs  in  the  interval  between  the  periods.  This  is  another 
argument  brought  against  the  ovular  theory,  because,  it  is  said,  if  men- 
struation depends  on  the  rupture  of  a  Graafian  follicle  and  the  emission 
of  an  ovule,  then  impregnation  should  only  take  place  during  or  imme- 
diately after  menstruation.  Coste  explains  this  by  supposing  that  it  is 
the  maturation  and  not  the  rupture  of  the  follicle  which  determines  the 
occurrence  of  menstruation,  and  that  the  follicle  may  remain  unrup- 
tured for  a  considerable  time  after  it  is  mature,  the  escape  of  the  ovule 
being  subsequently  determined  by  some  accidental  cause,  such  as  sexual 
excitement.  However  this  may  be,  there  is  good  reason  to  believe  that 
the  susceptibility  to  conception  is  greater  ckunng  the  menstrual  epochs. 
Raciborski  believes  that  in  the  large  proportion  of  cases  impregnation 
occurs  in  the  first  half  of  the  menstrual  interval,  or  in  the  few  days  im- 
mediately preceding  the  appearance  of  the  discharge.  There  are,  how- 
ever, very- numerous  exceptions,  for  in  Jewesses,  who  almost  invariably 
live  apart  from  their  husbands  for  eight  days  after  the  cessation  of  men- 
struation, impregnation  must  constantly  occur  at  some  other  period  of 
the  interval,  and  it  is  certain  that  they  are  not  less  prolifii3  than  other 
people.  This  rule  with  them  is  very  strictly  adhered  to,  as  will  be  seen 
by  the  accompanying  interesting  letter  from  a  medical  friend  who  is  a 
well-known  member  of  that  community,  and  which  I  have  permission 
to   publish.^     This  fact    is  of   itself  sufficient  to   disprove  the  theory 

1 10  Bernard  Street,  RusseU  Square,  July  21, 1873. 
My  Dear  Sir: 

1.  To  the  best  of  my  knowledge  and  belief,  the  law  which  prohibits  sexual  inter- 
course among  Jews  for  seven  clear  days  after  the  cessation  of  menstruation,  is 
almost  universally  observed,  the  exceptions  not  being  sufficient  to  vitiate  statistics. 
The  law  has  perhaps  fewer  exceptions  on  the  Continent — especially  Russia  and  Poland, 
where  the  Jewish  population  is  very  great — than  in  England.  Even  here,  however, 
women  who  observe  no  other  ceremonial  law  observe  this,  and  cling  to  it  after  every- 
thing else  is  thrown  overbpard.  There  are  doubtless  many  exceptions,  especially 
among  the  better  classes  in  England,  who  keep  only  thi'ee  days  after  the  cessation  of 
the  menses. 

2.  The  law  is — as  you  state — that  should  the  discharge  last  only  an  hour  or  so,  or 
should  there  be  only  one  gush  or  one  spot  on  the  linen,  the  five  days  during  which  the 
period  might,  continue  are  observed  ;  to  which  must  be  superadded  the  seven  clear  days 
— twelve  days  per  mensem  in  which  connection  is  disallowed.  Should  any  discharge 
be  seen  in  the  intei'-menstrual  period,  seven  days  would  have  to  be  kept,  but  not  the 
five,  for  such  irregular  discharge. 

3.  The  "bath  of  purification,"  which  must  contain  at  least  eighty  gallons,  is  used  on 
the  last  night  of  the  seven  clear  days.  It  is  not  used  till  after  a  bath  for  cleansing  pur- 
poses; and,  from  the  night  when  such  "purifying"  bath  is  used  .Jewisli  women  are 
accustomed  to  calculate  the  commencement  of  pregnancy.  That  you  should  not  have 
heard  it  is  not  strange:  its  mention  would  be  considered  highly  indelicate. 

4.  Jewish  women  reckon  their  pregnancy  to  last  nine  calendar  or  ten  lunar  months 
— 270  to  280  days.  There  are  no  s[)ecial  data  on  which  to  reckon  an  average,  nor  do 
1  know  of  any  books  on  the  subject,  except  some  Talmudic  authorities,  which  I  will 
look  u))  f(;r  you  if  you  desire  it.  Pray  make  no  apologies  for  writing  to  me:  any  in- 
formation I  possess  is  at  your  service. 

I  am,  dear  sir,  yours  very  truly, 
Dr.  Playfair.  '      A.'Asheb. 

P.  8. — The  liiblical  foundation  for  the  law  of  seven  clear  days  is  Leviticus  xv.,  verse 
19  to  the  end  of  the  cluipter— especially  verse  28. 


92  ORGANS  CONCERNED  IN  PARTURITION. 

advanced  by  Dr.  Avrard/  that  impregnation  is  impossible  in  the  latter 
half  of  the  menstrual  interval.  This,  and  the  other  reasons  referred  to, 
undoubtedly  throw  some  doubt  on  the  ovular  theory,  but  they  do  not 
seem  to  be  sufficient  to  justify  the  conclusion  that  menstruation  is  a 
phvsiological  process  altogether  independent  of  the  development  and 
maturation  of  the  Graafian  follicles.  All  that  they  can  be  fairly  held 
to  prove  is  that  the  escape  of  the  ovules  may  occur  independently  of 
menstruation,  but  the  weight  of  evidence  remains  strongly  in  favor  of 
the  theory  which  is  generally  received.  It  should  be  stated  that  Lawson 
Tait  attributes  considerable  influence  in  menstruation  to  the  Fallopian 
tubes  themselves ;  but  his  views  on  this  point,  based  on  observations 
made  after  the  removal  of  the  ovaries  for  certain  morbid  conditions, 
cannot  yet  be  taken  as  proved. 

Purpose  of  the  Menstrual  Loss. — The  cause  of  the  monthly  periodicity 
is  quite  unknown,  and  will  probably  always  remain  so.  Goodman  ^  has 
suggested  what  he  calls  the  "  cyclical  theory  of  menstruation,"  which 
relers  the  phenomena  to  a  general  condition  of  the  vascular  system 
specially  localizing  itself  in  the  generative  organs,  and  connected  with 
rhythmical  changes  in  their  nerve-centres.  It  does  not  seem  to  me, 
however,  that  he  has  satisfactorily  proved  the  recurrence  of  the  condi- 
tions which  his  ingenious  theory  assumes.  The  purpose  of  the  loss  of 
so  much  blood  is  also  somewhat  obscure.  To  a  certain  extent  it  must 
be  considered  an  accident  or  complication  of  ovulation,  produced  by  the 
vascular  turgescence.  Nor  is  it  essential  to  fecundation,  because  women 
often  conceive  during  lactation,  when  menstruation  is  suspended  or 
before  the  function  has  become  established.  It  may,  however,  serve  the 
negative  purpose  of  relieving  the  congested  uterine  capillaries  which  are 
periodically  tilled  with  a  supply  of  blood  for  the  great  growth  which 
takes  place  when  conception  has  occurred.  Thus  immediately  Ijefore 
each  period  the  uterus  may  be  considered  to  be  placed  by  the  afflux  of 
blood  in  a  state  of  preparation  for  the  function  it  may  be  suddenly  called 
upon  to  perform.  That  the  discharge  relieves  a  state  of  vascular  ten- 
sion which  accompanies  ovulation  is  proved  by  the  singular  phenomenon 
of  vicarious  menstruation  which  is  occasionally,  though  rarely,  met  with. 
It  occurs  in  cases  in  which,  from  some  unexplained  cause,  the  discharge 
does  not  escape  from  the  uterine  mucous  membrane.  Under  such  cir- 
cumstances a  more  or  less  regular  escape  of  blood  may  take  place  from 
other  sites.  The  most  common  situations  are  the  mucous  membranes  of 
the  stomach,  of  the  nasal  cavities,  or  of  the  lungs;  the  skin,  not  uncom- 
monly that  of  the  mammse,  probably  on  account  of  their  intimate  sym- 
pathetic relation  with  the  uterine  organs ;  from  the  surface  of  an  ulcer ; 
or  from  hemorrhoids.  It  is  a  noteworthy  fact  that  in  all  these  cases  the 
discharge  occurs  in  situations  where  its  external  escape  can  readily  take 
place.  This  strange  deviation  of  the  menstrual  discharge  may  be  taken 
as  a  sign  of  general  ill-health,  and  it  is  usually  met  with  in  delicate 
young  women  of  highly  mobile  nervous  constitution.  It  may,  however, 
begin  at  puberty,  and  it  has  even  been  observed  during  the  whole  sexual 
life.     The  recurrence  is  regular,  and  always  in  connection  with  the  men- 

1  Bev.  (le.  Therap.  Med.-Chir.,  1S57. 

^  American  Journal  of  Obstetrics,  Oct.,  1868. 


OVULATION  AND  MENSTRUATION.  93 

strual  nisus,  although  the  amount  of  blood  lost  is  much  less  than  in 
ordinary  menst  ruation. 

Cessation  of  Menstruation. — After  a  certain  time  changes  occur,  show- 
ing that  the  woman  is  no  longer  fitted  for  reproduction ;  menstruation 
ceases,  Graafian  follicles  are  no  longer  matured,  and  the  ovary  becomes 
shrivelled  and  wrinkled  on  its  surface.  Analogous  alterations  take 
place  in  the  uterus  and  its  appendages.  The  Fallopian  tubes  atrophy, 
and  are  not  unfrequently  obliterated.  The  uterus  decreases  in  size. 
The  cervix  undergoes  a  remarkable  change,  which  is  readily  detected  on 
vaginal  examination ;  the  proiection  of  the  cervix  into  the  vaginal  canal 
disappears,  and  the  orifice  of  the  os  uteri  in  old  women  is  found  to  be 
flush  with  thejiiofof  the  vagina,  in  a  large  number  of  cases  there  is, 
after  the  cessation  of  menstruation,  an  occlusion  both  of  the  external  and 
internal  os ;  the  canal  of  the  cervix  between  them,  however,  remains 
patulous,  and  is  not  unfrequently  distended  with  a  mucous  secretion. 

Period  of  Cessation. — The  age  at  which  menstruation  ceases  varies 
much  in  different  women.  In  certain  cases  it  may  cease  at  an  unusually 
early  age,  as  between  30  and  40  years,  or  it  may  continue  far  beyond 
the  average  time,  even  up  to  60  years ;  and  exceptional,  though  perhaps 
hardly  reliable,  instances  are  recorded  in  which  it  has  continued  even 
to  80  or  90  years.  These  arS,  however,  strange  anomalies,  which,  like 
cases  of  unusually  precocious  menstruation,  cannot  be  considered  as  hav- 
ing any  bearing  on  the  general  rule.  Most  cases  of  so-called  protracted 
menstruation  will  be  found  to  be  really  morbid  losses  of  blood  depend- 
ing on  malignant  or  other  forms  of  organic  disease,  the  existence  of 
which,  under  such  circumstances,  should  always  be  suspected. 

In  tliis  country  menstruation  usually  ceases  between  40  and  50  years 
of  age!  Raciborski  says  that  the  largest  number  of  cases  of  cessation 
are  met  with  in  the  46th  year.  It  is  generally  said  that  women  who 
commence  to  menstruate  when  very  young  cease  to  do  so  at  a  compara- 
tively early  age,  so  that  the  average  duration  of  the  function  is  about 
the  same  in  all  women.  Cazeaux  and  Raciborski,  whose  opinion  is 
strengthened  by  the  observations  of  Guy  in  1500  cases,^  think,  on  the 
contrary,  that  the  earlier  menstruation  commences  the  longer  it  lasts, 
early  menstruation  indicating  an  excess  of  vital  energy  which  continues 
during  the  whole  childbearing  life.  Climate  and  other  accidental  causes 
do  not  seem  to  have  as  much  effect  on  the  cessation  as  on  the  establish- 
ment of  the  function.  It  does  not  appear  to  cease  earlier  in  warm  than 
in  temperate  climates.  The  change  of  life  is  generally  indicated_by 
irregularities  in  the  recurrence  of  the  discharge.  It  seldom  ceases  sud- 
denly, l)ut  it  may  be  absent  for  one  or  more  periods,  and  then  occur 
irregularly;  or  it  may  become  profuse  or  scanty,  until  eventually  it 
entirely  stops.  The  popular  notions  as  to  the  extreme  danger  of  the 
menopause  are  probably  nnicli  exaggerated,  although  it  is  certain  that  at 
tliat  time  various  nervous  phenomena  are  apt  to  be  developed.  So  far 
from  having  a  ])r(;judicial  effect  on  the  health,  however,  it  is  not  an  un- 
common o])servation  to  see  an  hysterical  woman,  wlio  has  been  for  years 
a  martyr  to  uteriiK;  and  other  coiiiplaints,  apparently  take  a  new  lease 
of  life  when  her  uterine  functions  have  ceased  to  be  in  active  operation ; 

'  Mtd.  Times  and  Guz.,  1845. 


94  ORGANS  CONCERNED  IN  PARTURITION. 

and  statistical  tables  abundantly  prove  that  the  general  mortality  of  the 
sex  is  not  greater  at  this  than  at  any  other  time. 

[The  theory  that  the  average  duration  of  menstrual  life  is  thirty 
years,  and  that  the  period  of  cessation  is  usually  regulated  by  the  age  at 
which  menstruation  was  established,  is  an  error.  The  age  of  cessation 
is  nuich  more  irregular  than  that  of  commencement,  and  women  cease  to 
menstruate  at  all  ages  from  28  to  56,  and  even  beyond  60.  If  careful 
inquiry  is  made,  especially  among  women  in  the  higher  walks  of  life,  it 
will  be  found  that  those  who  begin  to  menstruate  at  9,  10,  11,  and  12 
years  of  age  often  continue  to  do  so  until  long  after  thirty  years  have 
passed,  and  that  it  is  not  uncommon  for  such  women  to  be  among  the 
latest  in  reaching  the  menopause.  I  have  known  the  menopause  to  be 
established  before  30,  and  menstruation  to  be  still  regular  at  62  years 
of  age. — Ed.] 


PART  11. 

PREGNANCY. 


CHAPTER  I. 

CONCEPTION  AND  GENEEATION. 

GENERATioisr  in  the  human  female,  as  in  all  mammals,  requires  the 
congress  of  the  two  sexes,  in  order  that  the  semen,  the  male  element  of 
generation,  may  be  brought  into  contact  with  the  ovule,  the  female  ele- 
ment of  generation. 

The  Semen. — The  semen  secreted  by  the  testicle  of  an  adult  male  is  a 
viscid,  opalescent  fluid,  forming  an  emulsion  when  mixed  with  water, 
and  having  a  peculiar  faint  odor,  which  is  attributed  to  the  secretions 
which  are  mixed  with  it,  such  as  those  from  the  prostate  and  Cowper's 
glands.  On  analysis  it  is  found  to  be  an  albuminous  fluid,  holding  in 
solution  various  salts,  principally  phosphates  and  chlorides,  and  an  ani- 
mal substance,  spermatin,  analogous  to  fibrin.  Examined  under  a  mag- 
nifying power  of  from  400  to  500  diameters,  it  consists  of  a  transparent 
and  homogeneous  fluid,  in  which  are  floating  a  certain  number  of  gran- 
ules and  epithelial  cells  derived  from  the  secretions  mixed  with  it,  and 
the  characteristic  sperm-cells  and  spermatozoa  which  form  its  essential 
constituents.  The  sperm-cells  are  those  occupying  the  tubuli  semeni^ri 
of  the  testicle.  Several  kinds  of  sperm-cells  are  described  which  receive 
their  name  from  the  position  they  occupy  with  regard  to  the  lumen  of 
the  tubule  (Fig.  44).  The  cells  which  are  next  to  the  wall  of  the  tubule 
are  called  the  outer  or  lining  cells.  They  are  more  or  less  flattened  in 
form,  and  are  situated  on  a  distinct  basement  membrane.  Internal  to 
this  layer  is  another,  consisting  of  round  cells,  the  nuclei  of  which  are 
in  a  state  of  proliferation  ;  this  is  the  intermediate  layer.  Between  this 
and  the  lumen  of  the  tubule  are  a  number  of  cells,  irregular  in  shape, 
amongst  which  are  imbedded  the  heads  of  the  spermatozoa,  the  tails  of 
which  ])roject  into  the  lumen.  The  spermatozoa  are  thought  to  arise 
from  this  innermost  layer  in  the  following  manner :  the  nuclei  of  the 
sperm-cells  proliferate,  and  from  their  subdivisions  arise  the  heads  of 
the  s])ermatozoa,  the  bodies  of  which  originate  from  the  ])r()to])lasm  of 
th(?  cells.  Bv  the  d(;f'oni position  of  the  5ul)sl;ui('c  in  wliicli  tlic  heads  of 
the  spermatozoa  are  imbedded  the  contained  s[)erniatozoa  become  liberated, 
and  move  about  freely  in  the  seminal  fluid.  As  seen  under  the  micro- 
scope, the  spermatozoa,  which  exist  in  healthy  semen  in  enormons  num- 
bers, present  the  appearance  of  minute  particles,  not  unlike  a  tadpole  in 

95 


96 


PEEGyAXCY. 


shape.  The  head  is  oval  and  flattened,  measuring  about  j-^jj-^-^j  of  an 
inch  in  breadth,  and  attached  to  it  is  a  delicate  filamentous  expansion  or 
tail,  which  tapers  to  a  point  so  fine  that  its  termination  cannot  be  seen 
by  the  highest  powers  of  the  microscope.  The  w^hole  spermatozoon 
measures  from  -^^  to  ^J-^-  of  an  inch  in  length.  The  spermatozoa  are 
observed  to  be  in  constant  motion,  sometimes  very  rapid,  sometimes  more 

Fig.  44. 


Section  of  Parts  of  three  Semeniferous  Tubules  of  the  Rat. 
a.  With  the  spermatozoa  least  arlvanced  in  develojuiieiit.    h.  More  advanced,    c.  Containing  fully-developed 
spermatozoa.   Between  tlie  tubules  are  seen  strands  of  interstitial  cells  and  lymph -spaces.   (From  a  prepara- 
tion by  Mr.  A.  Frazer.) 

gentle,  which  is  supposed  to  be  the  means  by  which  they  pass  upward 
through  the  female  genital  organs.  They  retain  their  vitality  and  poA\'er 
of  movement  for  a  considerable  time  after  emission,  provided  the  semen 
is  kept  at  a  temperature  similar  to  that  of  the  body.  Under  such  cir- 
cumstances they  have  been  observed  in  active  motion  from  forty-eight  to 
seventy-two  hours  after  ejaculation,  and  they  have  also  been  seen  alive 
in  the  testicle  as  long  as  twenty-four  hours  after  death.  In  all  proba- 
bility they  continue  active  much  longer  within  the  generative  organs,  as 
many  physiologists  have  observed  them  in  full  vitality  in  bitches  and 
I  rabbits  «eyen  or_e^ht  daysjifter  copiilation.  The  recent  experiments  of 
Haussman,  TioweveF,  sKow  that  theyTose  their  power  of  motion  in  the 
human  vagina  within  twelve  hours  after  coitus,  although  they  doubtless 
retain  it  longer  in  the  uterus  and  Fallopian  tubes.  Abundant  leucor- 
rheal  discharges  and  acrid  vaginal  secretions  destroy  their  movements, 
and  may  thus  cause  sterility  in  the  female.  On  account  of  their  mol)ility, 
the  spermatozoa  were  long  considered  to  be  independent  animalcules — 
a  view  which  is  by  no  means  exploded,  and  has  been  maintained  in  mod- 
ern times  by  Pouchet,  Joulin,  and  other  writers,  Avhile  Coste,  Robin, 
Kolliker,  etc.  liken  their  motion  to  that  of  ciliated  epithelium.  There 
can  be  no  doubt  that  the  fertilizing  power  of  the  semen  is  due  to  the 
presence  of  the  spermatozoa,  although  some  of  the  older  phvsiologists 
assigned  it  to  the  spermatic  fluid.     The  former  view,  however,  has  been 


CONCEPTION  AND   GENERATION. 


97 


conclusively  proved  by  the  experiments  of  Prevost  and  Dumas,  who 
found  that  on  carefully  removing  the  spermatozoa  by  filtration  the  semen 
lost  its  fecundating  properties. 

Sites  oL_Jj2}lii:(^g7iation. — There  has  been  great  difference  of  opinion  as 
to  the  part  of  the  genital  tract  in  which  the  spermatozoa  and  the  ovule 
come  into  contact,  and  in  which  impregnation,  therefore,  occurs.  Sperma- 
tozoa have  been  observed  in  all  parts  of  the  female  genital  organs  in 
animals  killed  shortly  after  coitus,  es]3ecially  in  the  Fallopian  tubes,  and 
even  on  the  surface  of  the  ovary.  The  phenomena  of  ovarian  gestation, 
and  the  fact  that  fecundation  has  been  proved  to  occur  in  certain  animals 
within  the  ovary,  tend  to  support  the  idea  that  it  may  also  occur  in  the 
human  female  before  the  rupture  of  the  Graafian  follicle.  In  order  to 
do  so,  however,  it  is  necessary  for  the  spermatozoa  to  penetrate  the  proper 
structure  of  the  follicle  and  the  epithelial  covering  of  the  ovary,  and  no 
one  has  actually  seen  them  doing  so.  Most  probably  the  contact  of  the 
spermatozoa  and  the  ovule  occurs  very  shortly  after  the  rupture  of  the 
follicle,  and  in  the  outer  part  of  the  Fallo]3ian  tubes.  Coste  maintains 
that  unless  the  ovule  is  impregnated  it  very  rapidly  degenerates  after 
being  expelled  from  the  ovary,  partly  by  inherent  changes  in  the  ovule 
itself,  and  partly  because  it  then  soon  becomes  invested  by  an  albuminous 
covering  which  is  impermeable  to  the  spermatozoa.  He  believes,  there- 
fore, that  impregnation  can  only  occur  either  on  the  surface  of  the  ovary 
or  just  within  the  fimbriated  extremity  of  the  tube. 

Mode  in  which  the  Ascent  of  the  Semen  is  Effected. — The  semen  is  proba- 
bly carried  upward  chiefly  by  the  inherent  mobility  of  the  spermatozoa. 
It  is  believed  by  some  that  this  is  assisted  by  other  agencies :  amongst 
them  are  mentioned  the  peristaltic  action  of  the  uterus  and  Fallopian 
tubes  ;  a  sort  of  capillary  attraction  effected  when  the  walls  of  the 
uterus  are  in  close  contact,  similar  to  the  move- 
ment of  fluid  in  minute  tubes ;  and  also  the 
vibratile  action  of  the  cilia  of  the  epithelium 
of  the  uterine  mucous  membrane.  The  action 
of  the  latter  is  extremely  doubtful,  for  they 
are  also  supposed  to  effect  the  descent  of  the 
ovule,  and  they  can  hardly  act  in  two  oppo- 
site ways.  The  movement  of  the  cilia  being 
from  Avithin  outward,  it  would  certainly 
oppose  rather  than  favor  the  progress  of  the 
S})erniatozoa.  It  must,  therefore,  be  admitted 
that  they  ascend  chiefly  throutyli  tlieir  own 
po^vers  of  motion"  Tliey  certainly  have  this 
power  to  a  remarkable  extent,  for  there  are 
numerous  cases  on  record  in  which  im})reg- 
nation  has  occurred  without  penetration,  and 
even  when  the  hymen  Avas  quite  entire,  and  in  Avliicli  tlie  semen  has  sim- 
ply l)een  deposited  on  the  exterior  of  the  vulva;  in  such  cases,  whi(di 
are  far  from  uncommon,  tlu;  spermatozoa  must  li;iv(;  found  their  way 
through  the  wliole  lengtli  of  the  vagina.  It  is  probable,  however,  that 
und(,'r  ordinary  circumstances  the  passage  of  the  spermatic  fluid  into  the 
uterus  is  facilitated  l>y  changes  which  take  place  in  the  cervix  during 
7 


Fig. 45. 


Oviim   of  Rabbit   containing 

Spermatozoa. 
Zona  pelluciila.    2.  The  fjernis,  con- 
sifltiiip;  of   two    large   cells,    several 
BJiiallor  cellH,  and  spermatozoa. 


98  PREGNANCY. 

the  sexual  orgasm,  in  the  course  of  which  the  os  uteri  is  said  to  dilate 
and  close  again  in  a  rhythmical  manner.^ 

Mode  of  Impregnation. — The  precise  method  in  which  the  spermatozoa 
effect  impregnation  was  long  a  matter  of  doubt.  It  is  now,  however, 
certain  that  they  actually  penetrate  the  ovule  and  reach  its  interior. 
This  has  been  conclusively  pi-oved  by  the  observations  of  Barry,  IMeiss- 
ner,  and  others,  who  have  seen  the  spermatozoa  within  the  external 
membrane  of  the  ovule  in  rabbits  (Fig.  45).  In  some  of  the  inverte- 
brata  a  canal  or  opening  exists  in  the  zona  pellucida,  through  which  the 
spermatozoa  pass.  No  such  aperture  has  yet  been  demonstrated  in  the 
ovules  of  manmials,  but  its  existence  is  far  from  improbable.  Accord- 
ing to  the  observations  of  Newport,  several  spermatozoa  enter  the  ovule, 
ami  the  greater  the  number  that  do  so  the  more  certain  fecundation  be- 
comes. After  the  spermatozoa  penetrate  the  zona  pellucida,  they  disin- 
tegrate and  mingle  with  the  yelk,  having,  while  doing  so,  imparted  to 
the  ovule  a  power  of  vitality  and  initiated  its  development  into  a  new 
being. 

Progress  of  the  Impregnated  Oimle  toward  the  Uterus. — The  length  of 
time  which  lapses  before  the  fecundated  ovule  arrives  in  the  cavity  of 
the  uterus  has  not  yet  been  ascertained,  and  it  probably  varies  under 
different  circumstances.  It  is  known  that  in  the  bitch  it  may  remain 
eight  or  ten  days  in  the  Fallopian  tube,  in  the  guinea-pig  three  or  four. 
In  the  human  female  the  ovum  has  never  been  discovered  in  the  cavity 
_of  the  uterus  before  the  tenth  or  twelfth  day  after  impregnation. 

Changes  which  the  Ovule  undergoes  immediately  before  and  after  Im- 
pregnation.— The  changes  which  occur  in  the  human  ovule  immediately 
before  and  after  impregnation,  and  during  its  progress  through  the  Fal- 
lopian tube,  are  only  known  to  us  by  analogy,  as,  of  course,  it  is  impos- 
sible to  study  them  by  actual  observation.  We  are  in  possession,  how- 
ever, of  accurate  information  of  what  has  been  made  out  in  the  lower 
animals,  and  it  is  reasonable  to  suppose  that  similar  changes  occur  in 
man.  Immediately  after  the  ovule  has  passed  into  the  Fallopian  tube, 
it  is  found  -to  be  surrounded  by  a  layer  of  granular  cells,  a  portion  of 
the  lining  membrane  of  the  Graafian  follicle,  which  was  described  as 
the  discus  proligerus.  As  it  proceeds  along  the  tube,  these  surrounding 
cells  disappear— partly,  it  is  supposed,  by  friction  on  the  walls  of  the 
tube,  and  partly  by  being  absorbed  to  nourish  the  ovule.  Be  this  as  it 
may,  before  long  they  are  no  longer  observed,  and  the  zona  pellucida 
forms  the  outermost  layer  of  the  ovule.  When  the  ovule  has  advanced 
some  distance  along  the  tube,  it  becomes  invested  Avith  a  covering  of 
albuminous  material,  which  is  deposited  around  it  in  successive  layers, 
the  thickness  of  which  varies  in  different  animals.  It  is  very  abundant 
in  birds,  in  whom  it  forms  the  familiar  white  of  the  Qgg.  In  some 
animals  it  has  not  been  detected,  so  tliat  its  presence  in  the  human  ovule 
is  uncertain.  Where  it  exists  it  doubtless  contributes  to  the  nourishment 
of  the  ovule.  Coincident  with  these  changes  is  the  disappearance  of  the 
germinal  vesicle.  At  the  same  time  the  yelk  contracts  and  becomes 
more  solid,  retiring  from  close  contact  with  the  zona  pellucida,  and 
thus  forming  a  species  of  cavity  between  the  outer  edge  of  the  yelk  and 
'  Hoio  do  (he  Spermatozoa  enter  the  Uterus  f  by  J.  Beck,  M.  D. 


CONCEPTION  AND   GENERATION. 


99 


the  vitelline  membrane,  which  in  some  animals  is  filled  with  a  trans- 
parent liquid.  Coincident  with  the  shrinking  of  the  yelk,  a  small  j 
granular  mass  of  a  rounded  form  is  ex- 
truded from  the  yelk  into  the  clear  space 
beneath  the  zona  pellucida.  At  a  later 
period  another  similar  mass  is  extruded. 
These  are  the  polar  c[lob;ides  (Fig.  46),  the 
origin  of  which~is~tliought  to  be  in  con- 
nection with  the  disappearance  of  the  ger- 
minal vesicle  and  the  germinal  spot.  These 
changes  occur  in  all  ovules,  whether  they 
are  impregnated  or  not,  but  if  the  ovule 
is  not  fecundated,  no  further  alterations 
occur.  Supposing  impregnation  has  taken 
place,  a  bright,  clear  vesicle,  called  the 
'^ikMa^Jiy^ISM'^}  very  similar  in  appearance 
to  a  drop  of  oil,  appears  in  the  centre  of 
the  yelk.  After  this  occurs  the  very  peculiar  phenomenon  known  as 
the  cleavage  of  the  yelk,  which  results  in  the  formation  of  the  layer  of 
cells  from  which  the  foetus  is  developed.  The  segmentation  of  the  yelk 
(Fig.  47)  occupies  in  mammals  the  whole  of  its  substance.  In  birds  the 
cleavage  is  confined  to  a  small  area  of  the  yelk  called  the  cicatricula  or 
blastoderm.  Hence  the  term  holoblastic  has  been  applied  to  the  ova  of 
mammals,  mesoblastic  to  those  of  birds.     It  divides  at  first  into  two 


Formation  of  the  "  Polar  Globule." 
.  Zona  pellucida,  containing  spermatozoa. 
2.  Yelk.     3  anrl  4.  Germinal   vesicle.     5. 
The  polar  globule. 


Segmentation  of  the  Yelk. 
A.  Ovum  with  first  embryo  cell.     b.  Division  of  embryo  cell  and  cleavage  of  the  yelk  around  it.      c,  d,  e. 

Further  division  of  the  yelk.  • 

halves,  and  at  the  same  time  the  vitelline  nucleus  becomes  constricted 
in  its  centre,  and  separates  into  two  portions,  one  of  which  forms  a  cen- 
tre for  eacli  of  the  lialves  into  which  the  yelk  has  divided.  Ea(!h  of 
these;  immediately  divides  into  two,  as  does  its  contained  portion  of  the 
vitelline  nucleus,  and  so  on  in  rapid  succession  until  the  whole  yelk  is 
divided  into  a  number  of  spheres,  each  of  which  consists  of  a  (;lump  of 
niu'lciitcd  proto|)lMsm. 

Jjy  these  (;<;ntinuous  dichotomous  divisions  the  whole  yelk  is  formed 


100  PREGNANCY. 


into  a  granular  mass,  which  from  its  supposed  resemblance  to  a  mulberry 
has  been  named  the  ')JMdfQJCI'Lk2^y-  When  the  subdivision  of  the  yelk 
is  completed,  its  separate  spheres  become  converted  into  cells,  consisting 
of  a  fine  membrane  with  granular  contents.  These  cells  unite  by  their 
edges  to  form  a  continuous  membrane  (Fig.  48),  which,  through  the 
expansion  of  the  muriform  body  by  fluid  which  forms  in  its  interior,  is 
distended  until  it  forms  a  lining  to  the  zona  pellucida.  This  is  the 
hlasterdomic  membrane,  from  which  the  foetus  is  developed.  By  this 
time~tHe  ovum  has  reached  the  uterus ;  and  before  proceeding  to  con- 
sider the  further  changes  which  it  undergoes,  it  will  be  well  to  study 
the  alteration  which  the  stimulus  of  impregnation  has  set  on  foot  in  the 
mucous  membrane  of  the  uteras,  in  order  to  prepare  it  for  the  reception 
and  growth  of  its  contents. 


Fig.  4S. 


Formation  of  the  Blastodermic  Membrane  from  the  Cells  of  the  Muriform  Body.    (After  Joulin.) 
1.  Layer  of  alljumiiioub  niatenal  snnouiidlug  2.  The  zona  pellucida. 

Changes  in  the  Uterine  Mucous  Ifembrane  consequent  on  Pregnancy. — 
— Even  before  the  ovum  reaches  the  uterus  the  mucous  membrane  be- 
comes thickened  and  vascular,  so  that  its  opposing  surfaces  entirely  ^fi  11 
the  uterine  cavity.  These  changes  may  be  said  to  be  the  same  in  kind 
— aithough  more  marked  and  extensive  in  degree — as  the  alterations 
which  take  place  in  the  mucous  membrane  in  connection  with  each 
menstrual  period.  The  result  is  the  formation  of  a  distinct  membrane, 
which  affords  the  ovum  a  safe  anchorage  and  protection  until  its  connec- 
tions Avith  the  uterus  are  more  fully  developed.  After  delivery,  this 
membrane,  Avhich  is  by  that  time  quite  altered  in  appearance,  is  at  least 
partially  thrown  off  with  the  ovum ;  on  which  account  it  has  received 
the  name  of  the  decidiLa  or  caduca. 

Divisions  of  the  Decidua. — The  decidua  consists  of  two  principal  ]X)r- 
tions,  which  in  early  pregnancy  are  separated  from  each  other  liy  a  con- 
siderable interspace.  One  of  these,  called  the  decidua  vera,  lines  the 
entire  uterine  cavity,  and  is,  no  doul^t,  the  original  mucous  lining  of  the 


CONCEPTION  AND   GENERATION.  101 

uterus  greatly  hypertrophied.  The  second,  the  decidua  reflexa,  is  closely 
applied  round  the  ovum,  and  it  is  probably  formed  by  the  sprouting  of 
the  decidua  vera  around  the  ovum  at  the  point  on  which  the  latter  rests, 
so  that  it  eventually  completely  surrounds  it.  As  the  ovum  enlarges, 
the  decidua  reflexa  is  necessarily  stretched,  until  it  comes  everywhere 
into  contact  with  the  decidua  vera,  wath  which  it  firmly  unites.  After 
the  third  month  of  pregnancy  true  union  has  occurred,  and  the  two 
layers  of  decidua  are  no  longer  separate.  The  decidua  serotina,  which 
is  described  as  a  third  portion,  is  merely  that  part  of  the  decidua  vera 
on  which  the  ovum  rests  and  where  the  placenta  is  eventually  developed. 
Vietvs  of  William  and  John  Hunter. — It  is  needless  to  refer  to  the 
various  views  which  have  been  held  by  anatomists  as  to  the  structure 
and  formation  of  the  decidua.  That  taught  by  John  Hunter  was  long 
believed  to  be  correct,  and  down  to  a  recent  date  it  received  the  adhe- 
rence of  most  physiologists.  He  believed  the  decidua  to  be  an  inflamma- 
tory exudation,  which  on  account  of  the  stimulus  of  pregnancy  was 
thrown  out  all  over  the  cavity  of  the  uterus,  and  soon  formed  a  distinct 
lining  membrane  to  it.  When  the  ovum  reached  the  uterine  orifice  of 
the  Fallopian  tube  it  found  its  entrance  barred  by  this  new  membrane, 
which  accordingly  it  pushed  before  it.  This  separated  portion  formed  a 
covering  to  the  ovum  and  became  the  decidua  reflexa,  while  a  fresh  exu- 
dation took  place  at  that  portion  of  the  uterine  wall  which  was  thus  laid 
bare,  and  this  became  the  decidua  vera.  Williani_Hunter  had  much 
more  correct  views  of  the  decidua,  the  accuracy  of  which  was  at  the 
time  much  contested,  but  which  have  recently  received  full  recognition. 
He  describes  the  decidua  in  his  earlier  writings  as  a  hypertrophy  of  the] 
uterine  mucous  membrane  itself — a  view  which  is  now  held  by  all! 
physiologists. 

Structure  of  the  Decidua. — When  the  decidua  is  first  formed,  it  is  a 
hollow  triangular  sac  lining  the  uterine  cavity  (Fig.  49),  and  having 
three  openings  into  it — those  of  the  Fallopian  tubes  at  its  upper  angles, 
and  one,  corresponding  to  the  internal  os  uteri,  below.  If,  as  is  gener- 
ally the  case,  it  is  thick  and  pulpy,  these  openings  are  closed  up  and 
can  no  longer  be  detected.  In  early  pregnancy  it  is  well  developed,  and 
continues  to  grow  up  to  the  third  month  of  utero-gestation.  After  that 
time  it  commences  to  atrophy,  its  adhesion  with  the  uterine  walls  less- 
ens, it  becomes  thin  and  transparent,  and  is  ready  for  expulsion  when 
delivery  is  effected.  When  it  is  most  developed,  a  careful  examination 
of  the  decidua  enables  us  to  detect  in  it  all  the  elements  of  the  uterine 
mucous  membrane  greatly  hypertrophied.  Its  substance  chiefly  consists 
of  large  round  or  oval  nucleated  cells  and  elongated  fibres,  mixed  with 
the  tubular  uterine  gland-ducts,  which  are  much  elongated,  and  filled 
with  cylindrical  epithelium  cells  and  a  small  (jnantity  of  milkv  fluid. 
According  to  Friedlander,  the  decidua  is  divisible  into  two  layers  :  the 
iiiiier,  being  formed  by  a  prolifi'ration  of  the  corpuscles  of  the  sub-cpi- 
tlielial  connective  tissue  of  the  mucous  membrane;  the  deeper,  in  contact 
with  the  uterine  walls,  out  of  flattened  or  compressed  j^land-ducts.  In 
an  early  abortion  the  extremities  of  these  ducts  may  be  observed  by  a 
lens,  on  the  external  or  uterine  surface  of  the  decidua,  occujwing  the 
summit  of  minute  projections  sei)arated  from  each  other  by  depressions. 


102 


PREGNANCY. 


If  these  projections  be  bisected  they  will  be  found  to  contain  little  cavi- 
ties, filled  with  lactescent  fluid,  which  were  first  described  by  IMontgom- 
ery  of  Dublin^  and  are  known  as  Montgomery^ s  cups.     They  are  in  fact 


Fig.  49. 


Aborted  Ovum  of  about  forty  days,  showing  the  Triangular  Shape  of  the  Decidua  (which  is  laid 
open),  and  the  Aperture  of  the  Fallopian  Tube.   (After  Coste.) 

the  dilated  canals  of  the  uterine  tubular  glands.  On  the  internal  surface 
of  such  an  early  decidua  a  number  of  shallow  depressions  may  be  made 
out,  which  are  the  open  mouths  of  these  ducts. 


Fig.  50. 


Fig.  51. 


Fig.  52. 


Formation  of  Decidua. 
(Tlie  decidua  is  colored  black  ; 
tlie  ovum  is  represented  as 
eiifraged  between  tvo  pro- 
jecting folds  of  membrane.) 


Projecting  Folds  of  Mem- 
brane growing  up  around 
the  Ovum.   . 


(After  Dalton.) 


Showing  Ovum  completely  sur- 
round'ed  by  tlie  Decidua  Re- 
flexa. 


Formation  of  the  Decidua  Reflexa.-^'SS'h.ew  the  ovum  reaches  the  ute- 
rine cavity,  it  soon  becomes  imbedded  in  the  folds  of  the  hypertrophied 
mucous  membrane,  which  almost  entirely  fills  the  uterine  cavity.     As  a 


CONCEPTION  AND  GENERATION.  103 

rule,  it  is  attached  to  some  point  near  the  opening  of  a  Fallopian  tube, 
the  swollen  folds  of  mucous  membrane  preventing  its  descent  to  the 
lower  part  of  the  uterus ;  in  exceptional  circumstances,  however — as  in ' 
women  who  have  borne  many  children  and  have  a  more  than  usually 
dilated  uterine  cavity — it  may  fix  itself  at  a  point  much  nearer  the 
internal  os  uteri.  According  to  the  now  generally  accepted  opinion  of 
Coste,  the  mucous  membrane  at  the  base  of  the  ovum  soon  begins  to 
sprout  around  it,  and  gradually  extends  until  it  eventually  covers  the  ovum 
(Figs.  50—52)  and  forms  the  decidua  reflexa.  Coste  describes,  under 
the  name  of  the  umbilious,  a  small  depression  at  the  most  prominent  part 
of  the  ovum,  which  he  considers  to  be  the  indication  of  the  point  where 
the  closure  of  the  decidua  reflexa  is  eifectecl.  There  are  some  objections 
to  this  theory,  for  no  one  has  seen  the  decidua  reflexa  incomplete  and  in 
the  process  of  formation,  and  on  examining  its  external  surface — that  is, 
the  one  farthest  from  the  ovum — its  microscopical  appearance  is  identi- 

FiG.  53. 


An  Ovum  removed  from  Uterus,  and  part  of  the  Decidua  Vera  cut  away.    (After  Coste.) 

a.  Decidua  vera,  showing  the  follicles  opening  ou  its  inner  surface,     b.  Inner  extremity  of  Fallopian  tube. 

c.  Flap  of  decidua  reflexa.     d.  Ovum. 

cal  with  that  of  the  inner  surface  of  the  decidua  vera.  To  meet  these 
difliculties,  Weber  and  Goodsir,  whose  views  have  been  adopted  by 
Priestley,  contended  that  the  decidua  reflexa  is  "  the  primary  lamina  of 
the  mucous  membrane,  which,  when  the  ovum  enters  the  uterus,  sepa- 
rates in  two-thirds  of  its  extent  from  the  layers  beneath  it,  to  adhere  to 
the  ovum  ;  the  remaining  third  remains  attached,  and  forms  a  centre  of 
nutrition."  According  to  this  view,  the  decidua  vera  would  be  a  sub- 
sefjuent  growth  over  the  separated  jx^rtion,  and  the  decidua  scrotina  the 
portion  of  the  primary  lamina  which  remained  attached.  In  tliis  way 
the  fiict  of  the  op])os(!(l  surfaces  of  the  decidua  vera  and  reflexa  being 
identical  in  structure  would  be  accounted  for.  *The  difficulty  which  this 
ther)^'\^  is  thus  intended  to  meet  does  n(jt  seem  so  great  as  is  supposed ; 
for  if,  as  is  likely,  it  is  only  the  epithelial  or  internal  surface  of  the 
mucous  membrane  which  sprouts  over  the  ovum,  and  not  its  deeper 
layers,,  the  fiu^ts  of  the  case  would  be  suffi(.'iently  met  by  Coste's  view. 


104  PREGNANCY. 

Up  to  the  third  month  of  pregnancy  the  deoiclua  reflexa  and  vera  are 
not  in  close  contact,  and  there  may  even  be  a  considerable  interspace  be- 
tween them,  which  sometimes  contains  a  small  quantity  of  mucous  fluid, 
called  the  Iii/drojjer-ione.  This  fact  may  account  for  the  curious  circum- 
stance, of  \\hich  many  instances  are  on  record,  that  a  uterine  sound  may 
be  passed  into  a  gravid  uterus  in  the  early  months  of  pregnancy  without 
necessarily  producing  abortion,  and  also  lor  the  occasional  occurrence  of 
menstruation  after  concej^tion  (Figs.  53  and  80).  Eventually,  by  the 
groM-th  of  the  ovum,  the  decidua  reflexa  comes  closely  into  contact  with 
the  vera,  and  the  two  become  intimately  blended  and  inseparable. 

Decidua  at  the  Mid  of  Pregnancy  and  after  Delivery. — As  pregnancy 
advances,  the  decidua  alters  in  appearance  and  becomes  fibrous  and  thin. 
In  the  later  months  of  utero-gestation  fatty  degeneration  of  its  structure 
commences,  its  vessels  and  glands  are  obliterated,  and  its  adhesion  to  the 
uterine  walls  is  lessened,  so  as  to  prepare  it  for  separation.  As  we  shall 
subsequently  see,  this  fatty  degeneration  was  assumed  by  Simpson  to  be 
the  determining  cause  of  labor  at  term.  After  the  eighth  month,  thrombi 
form  in  the  veins  lying  underneath  the  decidua  serotina,  and  at  the  end 
of  pregnancy  they  are  described  by  LeopokP  as  having  become,  to  a 
great  extent,  obliterated.  This,  he  supposes,  may  have  some  effect  in 
inducing  the  contractions  of  the  uterus  in  labor. 

Views  of  Robin. — It  was  long  believed  that  the  entire  decidua  was 
thrown  off  after  labor,  leaving  the  muscular  coat  of  the  uterus  bare  and 
denuded,  and  that  a  new  mucous  membrane  was  formed  during  con- 
valescence. According  to  Robin,^  whose  views  are  corroborated  by 
Priestley,  no  such  denudation  of  the  muscular  tissue  of  the  uterus  ever 
occurs,  but  a  portion  of  the  decidua  always  remains  attached  after 
delivery.  After  the  fourth  month  of  pregnancy  they  believe  that  a  new 
raucous  membrane  is  formed  under  the  decidua,  which  remains  in  a 
somewhat  imperfect  condition  till  after  delivery,  when  it  rapidly 
develops  and  assumes  the  proper  functions  of  the  mucous  lining  of 
the  uterus.  Robin  also  believes  that  that  portion  of  the  decidua  Avhich 
covers  the  placental  site,  the  so-called  decidua  serotina,  is  not  thrown 
off  with  the  membranes,  like  the  decidua  vera  and  reflexa,  but  remains 
attached  to  the  uterine  walls,  a  thin  layer  of  it  only  being  expelled  with 
the  placenta,  on  which  it  may  be  observed.  Duncan^  entirely  dissents 
from  these  views,  and  does  not  admit  the  formation  of  a  new  mucous 
membrane  durino;  the  later  months  of  utero-ffestation.  He  believes  that 
the  greater  part  of  the  decidua  is  thrown  off,  but  that  part  remains,  and 
from  this  the  fresh  mucous  membrane  is  developed.  This  view  is  sim- 
ilar to  that  of  Spiegelberg,  who  holds  that  the  portion  of  the  decidua 
that  is  expelled  is  the  more  superficial  of  the  two  layers  described  by 
Friedlander,  composed  chiefly  of  the  epithelial  elements,  ^\\\\\Q  the 
deeper  or  glandular  layer  remains  attached  to  the  walls  of  the  uterus. 
From  the  epithelium  of  the  glands  a  new  epithelial  layer  is  rapidly 
developed  after  delivery.  LeopokP  has  shown  that  the  uterine  mucous 
membrane  is  completely  re-formed  within  six  weeks  after  delivery,  and 
that  its  regeneration  is  sometimes  completed  as  early  as  the  end  of  the 

1  Arcb.f.  Gyn.,  B.  xi.  H.  3.  =  jfemoirea  de  I' Acad.  Imp.  dc  Med.,  1861. 

'^  Beseurches  in  Obnteirics,  p.  186  et  seq.         *  Arch.  /.  Gyn.,  B.  xii.  H.  2. 


CONCEPTION  AND   GENERATION. 


105 


third  week.  This  theory  bears  on  the  well-known  analogy  of  the 
uterus  after  delivery  to  the  stump  of  an  amputated  limb — an  old  simile, 
principally  based  on  the  erroneous  theory  that  the  whole  muscular  tissue 
of  the  uterus  was  laid  bare.  This,  as  we  have  seen,  is  not  the  case,  but 
the  simile  so  far  holds  good  in  that  the  mucous  lining  is  deprived  of  its 
epithelial  covering ;  and  this  fact,  together  with  the  existence  of  numer- 
ous open  veins  on  the  interior  of  the  uterus,  readily  explains  the  extreme 
susceptibility  to  septic  absorption  which  forms  so  peculiar  a  character- 
istic of  the  puerperal  state. 

Changes  in  the  Ovum. — Before  we  commenced  the  study  of  the 
decidua  we  had  traced  the  impregnated  ovum  into  the  uterine  cavity, 
and  described  the  formation  of  the  blastodermic  membrane  by  the  junc- 
tion of  the  cells  of  the  muriform  body.  We  must  now  proceed  to  con- 
sider the  further  changes  which  result  in  the  development  of  the  foetus 
and  of  the  membranes  that  surround  it.  It  would  be  quite  out  of  place 
in  a  work  of  this  kind  to  enter  into  the  subject  of  embryology  at  any 
leno;th,  and  we  must  therefore  be  content  with  such  details  as  are  of 
importance  from  a  practical  point  of  view. 

Division  of  the  Blastodermic  Membrane  into  Layers. — The  blasto- 
dermic membrane,  which  forms  a  complete  spherical  lining  to  the 
ovum  between  the  yelk  and  the  zona  pellucicla,  soon  divides  into  two 
layers — the  most  external,  called  the  epiblast,  and  an  internal,  the  hypo- 
blast— and  between  them  is  subsequently  developed  a  third,  known  as 
the  mesoblast.  From  these  three  layers  are  formed  the  entire  foetus : 
the  epiblast  giving  origin  to  the  central  nervous  system,  to  the  super-  ( 
ficmlJj^m_sfJi.e»skiii*  and  aiding  in  formation  of  the  organs  of  .,sp£cial 
sense_and  of  the  amnion ;  the  hypoblast  forming  the  epithelial  lining 
membrane  of  the  alimentflvv  and  respiratory  tracts,  and  of  the  tubes  and 


g;lands  in  connection  with  them.  andHielping  in  the  development  of  Jhe 
yelk-sac ;  the  niesoblast^iving  rise  to  the  skeleton,  the  muscles,  the 
connective  tissues,  tlic  va^ilar  system,  the  genito-urinaryorganSj_and 
taEmg  part  in  the  formation  oT  all_tJie  membranes. 

The  Area  Germinativa. — Almost  immediaTeTy  after  the  separation  of 
the  blastodermic  membrane  into  lay- 
ers one  part  of  it  becomes  thickened 
by  the  aggregation  of  cells,  and  is 
called  the  area  germinativa.  This 
is  at  first  round  and  then  oval  in 
shape,  and  in  its  centre  the  first 
indication  of  the  embryo  may  be 
detected  in  the  form  of  a  narrow 
straiglit  line,  the  primitive  trace. 
Surnninding  it  are  some  cjclls  more 
translucent  than  those  of  the  rest 
of  the  area  germinativa,  and  hence 
call  oil  the  area  pcllimda,  (Fig.  54). 


In  ihmt  of  the  primitive  tra(;e  two 
elevated  ridges  soon  arise,  the_/am- 
inm  dorsales,  which  in(;lude  between 
them  a  groove — the  medullary  groove — and  gi-adually  unite  posteriori}' 


Diam-Jiin  of  Aroii  Ocrminutiva,  sliowinjj  the 
I'riiiiitivc  'rrace  and  Area  I'ellufida. 


106 


PREGNANCY. 


Fig.  55. 


to  form  a  cavity  within  which  the  cerebro-spinal  axis  is  subsequently 
developed.  The  medullary  groove  as  it  grows  backward  overlaps  the 
primitive  trace,  which  disappears.  The  embryo  is  differentiated  from 
the  rest  of  the  blastoderm  by  a  fold  anteriorly,  which  is  called  the 
cephalic  or  head  fold.  Another  fold  afterward  appears  posteriorly, 
which  is  called  the  caudal  or  tail  fold.  Laterally  folds  also  arise. 
These  folds  all  tend  to  grow  toward  the  centre  of  the  under  surface  of 
what  will  be  .the  embryo. 

The  mesoblastic  layer  of  the  blastoderm,  except  that  part  which  forms 
the  axis  of  the  embryo,  splits  into  an  upper  layer,  the  somato-pleure, 
which  is  beneath  the  epiblast,  and  a  lower  layer,  the  splanchno-pleure, 
which  lies  upon  the  hypoblast.  The  space  formed  by  this  cleavage  of 
the  mesoblast  is  called  the  pleuro-peritoneal  cavity.  The  somato-pleure 
is  engaged  in  the  formation  of  the  body  walls  of  the  embryo.  The 
splanchno-pleure  forms  the  walls  of  the  alimentary  tract. 

Formation  of  the  Amnion. — Processes  arise  from  the  somato-pleure 
anteriorly,  posteriorly,  and  laterally,  which  gradually  arch  over  the 

dorsal  surface  of  the  foetus  until  they 
meet  each  other  and  form  a  complete 
envelope  to  it.  At  the  ventral  surface 
these  processes  are  separated  by  the 
whole  length  of  the  embryo,  but  they 
here  also  gradually  approach  each 
other,  and  eventually  surround  what 
is  subsequently  the  umbilical  cord, 
and  blend  with  the  integument  of 
the  foetus  at  the  point  of  its  inser- 
tion. In  this  way  is  formed  the  am- 
nion  (Fig.  55),  consisting  of  two 
layers :  the  internal,  derived  from  the 
epiblast,  is  formed  of  tessellated  epi- 
thelial cells;  the  external,  arising  from 
the  mesoblast,  is  formed  of  cells  like 
those  of  young  connective  tissue.  Be- 
fore the  folds  of  the  amnion  unite,  the 
free  edge  of  each  is  bent  outward  and 
spreads  around  the  ovum,  immediately  within  the  zona  pelhicida,  form- 
ing a  lining  to  it,  termed  by  Turner  the  subzonal  membrane,  which  is 
connected  with  the  development  of  the  chorion.  The  amnion  is  the 
most  internal  of  the  membranes  surrounding  the  foetus,  and  will  pres- 
ently be  studied  more  in  detail.  It  soon  becomes  distended  with  fluid, 
the  liquor  amnii,  and  as  tliis  increases  in  amount  it  separates  tli&  ajunion 
more  and  more  from  the  foetus. 

Chnnr/es  in  the  Hypoblast. — During  this  time  the  innermost  layer  of 
the  blastodermic  membrane  or  liypoblast  is  also  developing  two  pro- 
jections at  either  extremity  of  the  foetus,  and  these  gradually  approach 
each  other  anteriorly.  As  the  hypoblast  is  in  contact  with  the  yelk,  when 
these  meet  they  have  the  effect  of  dividing  the  yelk  into  two  portions. 
One,  and  the  smaller  of  the  two,  forms  eventually  the  intestinal  canal 
of  the  foetus ;  the  other,  and  much  the  larger,  contains  the  greater  por- 


Development  of  the  Amnion. 
1.  Vitelline  membrane.  2.  External  layer  of 
blastodermic  membrane.  3.  Internal  layers 
foi'ming  the  nnibilical  vesicle.  4.  Umbilical 
vessels.  5.  Projections  forming  amnions. 
6.  Embryo.    7.  Allantois. 


CONCEPTION  AND   OENEBATION. 


107 


tiou  of  the  yelk,  and  forms  the  ephemeral  structure  known  as  the  umbili- 
cal vesicle,  from  which  the  foetus  derives  most  of  its  nourishment  during 
the  early  stage  of  its  existence.  Its  communication  with  the  abdominal 
cavity  of  the  foetus  is  through  the  constricted  portion  at  the  point  of 


Fig.  57. 


1.  Exo-chorion.    2.  External  layer  of  blastodermic  membrane.    3.  Umbilical  vesicle.    4.  Its  vessels. 
5.  Aumiou.    6.  Embryo.    7.  AUautois  increasing  in  size. 

division  called  the  vitelline  duct  (Fig.  56),  An  artery  and  vein,  the 
omphcdo-mesenteric,  ramify  on  the  vesicle  and  its  duct. 
~  As  the  amnion  mcreases  in  size,  it  pushes  back  the  umbilical  vesicle 
toward  the  external  membrane  of  the  ovum,  between  which  and  the 
amnion  it  lies  (Fig.  57) ;  and  when  the  allantois  is  developed,  it  ceases 
to  be  of  any  use,  and  rapidly  shrinks  and  dwindles  away.  In  most 
mammals  no  trace  of  it  can  be  found  after  the  fourth  month  of  utero- 
gestation ;  in  some,  including  the  human  female,  it 
is  said  to  exist  as  a  minute  vesicle  at  the  placental 
end  of  the  umbilical  cord  at  the  full  period  of  preg- 
nancy. The  umbilical  vesicle  is  filled  with  a  yel- 
lowish fluid,  containing  many  oil-  and  fat-globules, 
similar  to  the  yelk  of  an  egg. 

The  Allantois. — Somewhere  about  the  twentieth 
day  after  conception  a  small  vesicle  is  formed  toward 
the  caudal  extremity  of  the  foetus,  which  is  called 
the  allantois.  This  membrane  in  mammals  is  im- 
portant, as  it  forms  the  greater  part  of  the  foetal 
placenta,  a  small  portion  of  it  remaining  inside  the 
body  permanently  as  the  bladder.  It  begins  as  a 
diverticulum  from  the  lower  part  of  the  intestinal 
canal.  This,  at  first  spherictal,  raj>idly  develops  and 
becomes  pyriform  in  shape,  while,  by  a  process  of 
constriction  similar  to  that  whi(^ii  oc<'Ui's  in  the  vitel- 
lus  to  fi)rra  the  umbilical  vesicle,  it  becomes  divided  into  two  parts,  com- 
municating with  each  other,  the  smaller  of  them  being  eventually 
develop(!d  into  the  urinary  bladder.  The  larger  portion,  leaving  the 
abdominal   cavity  along  with  the  vitelline  duct,  rajiidly  grows  until  it 


An     Emhryo 
twenty- five 


days 


open.    (After  Coste.) 
a.  Chorion.    6.  Amnion. 

c.  Cavity  of  chorion. 

d.  Umbilical  vesicle. 

e.  Pedicle  of  allantois. 
/.  Embryo. 


108  PREGNANCY. 

comes  into  contact  with  the  most  external  ovnlar  membrane,  the  chorion, 
over  the  entire  inner  surface  of  which  it  spreads.  In  this  part  vessels 
soon  develop — namely,  the  two  umbilical  arteries,  derived  from  the 
abdominal  aorta,  and  two  umbilical  veins,  one  of  which  subsequently 
disappears ;  these,  along  with  the  vitelline  duct  and  the  pedicle  of  the 
allantois,  form  the  umbilical  cord.  The  main  and  very  important  func- 
tion of  the  allantois,  therefore,  is  to  carry  the  foetal  vessels  up  to  the 
inner  surface  of  the  subzonal  membrane.  Besides  this  purpose,  the  allan- 
tois, at  a  very  early  period,  may  receive  the  excretions  of  the  foetus  and 

Fig.  58. 


1.  Exo-chorion.    2.  External  layer  of  the  blastodermic  membrane.    3.  Allantois.   4.  Umbilical  vesicle. 
5.  Amnion.    6.  Embryo.   7.  Pedicle  of  allantois. 

serve  as  an  excrementitious  organ.  According  to  Cazeanx,  scarcely  a 
trace  of  the  allantois  can  be  seen  a  few  days  after  its  formation.  Its 
lower  part  or  pedicle,  however,  long  remains  distinct,  and  forms  part  of 
the  umbilical  cord ;  and  traces  of  it  may  be  found  even  in  adult  life  in 
the  form  of  the  urachus,  which  is  really  the  dwindled  pedicle  and  forms 
one  of  the  ligaments  of  the  bladder. 

The  Corps  Reticule  or  Vitnfonn  Body. — Between  the  chorion  and 
amnion  is  often  found  a  gelatinous  fluid,  with  minute  filamentous  pro- 
cesses traversing  it,  called  by  Velpeau  the  coips  reticule,  which  is  not  met 
with  until  the  allantois  comes  into  contact  with  the  chorion,  and  which 
seems  to  be  formed  out  of  the  tissues  of  that  vesicle.  It  is  analogous 
to  the  so-called  Wharton's  jelly  found  in  the  umbilical  cord.  AA  hen 
first  formed  it  is  highly  vascular,  but  the  vessels  entirely  disappear  after 
the  placenta  is  formed,  and  the  remainder  of  the  chorionic  villi  atrophy. 
Sometimes  it  exists  in  considerable  quantities,  and  should  the  chorion 
rupture  at  the  end  of  pregnancy  it  may  escape  and  give  rise  to  an  errone- 
ous impression  that  the  liquor  amnii  has  been  discharged. 

Recapitulation. — Before  proceeding  to  consider  the  foetal  envelopes 
more  at  length,  it  may  be  useful  to  recapitulate  the  structures  already 
alluded  to  as  forming  the  ovum.     In  this  we  find — 

1.  The  embryo  itself. 

2.  A  fluid,  the  liquor  amnii,  in  which  it  floats. 


CONCEPTION  AND  OENEBATION.  109 

3.  The  amnion,  a  purely  ftjetal  membrane  surrounding  the  embryo, 
and  containing  the  liquor  amnii. 

4.  The  umbilical  vesicle,  containing  the  greater  portion  of  the  yelk, 
serving  as  a  source  of  nutrition  to  the  early  embryo  through  the  vitelline 
duct,  and  on  which  ramify  the  omphalo-mesenteric  vessels. 

5.  The  allantois,  a  vesicle  proceeding  from  the  caudal  extremity  of  the 
embryo,  spreading  itself  over  the  interior  of  the  ovum,  and  serving  as  a 
channel  of  vascular  communication  between  the  chorion  and  the  foetus 
through  the  umbilical  vessels. 

6.  An  interspace  between  the  outer  layer  of  the  ovum  and  the  amnion, 
in  which  is  contained  the  umbilical  vesicle  and  allantois  and  the  corps  reti- 
cule of  Velpeau. 

7.  The  outer  layer  of  the  ovum,  along  with  the  subzonal  membrane, 
forming  the  chorion  and  placenta. 

The  Amnion. — The  amnion  is  the  most  internal  of  the  two  membranes 
surrounding  the  foetus ;  its  origin  at  an  early  period  of  foetal  life  has 
already  been  described.  It  is  a  perfectly  smooth,  transparent,  but  tough 
membrane,  continuous  with  the  integument  of  the  foetus  at  the  ijisertion 
of  the  umbilical  cord,  round  which  it  forms  a  sheath.  Soon  after  it  is 
formed  it  becomes  distended  with  a  fluid,  the  liquor  amnii,  in  which  the 
foetus  is  suspended  and  floats.  This  fluid  increases  gradually  in  quantity, 
distending  the  amnion  as  it  does  so,  until  this  is  brought  into  contact 
with  the  inner  surface  of  the  chorion,  from  which  it  was  at  first  sepa- 
rated by  a  considerable  interspace. 

/Structure  of  the  Amnion. — The  internal  surface  of  the  amnion  is 
smooth  and  glistening,  and  on  microscopic  examination  it  is  found  to 
consist  of  a  layer  of  flattened  cells,  each  containing  a  large  nucleus. 
These  rest  on  a  stratum  of  fibrous  tissue  which  gives  to  the  membrane 
its  toughness,  and  by  which  it  is  attached  to  the  inner  surface  of  the 
chorion.     It  is  entirely  destitute  of  vessels^  nerveSj_and  lymphatics. 

The  Liquor  Amnii. — TliequaMityl)Tlh^  TiquOT  i  varies  much  at 

different  periods  of  pregnancy.  In  the  early  months  it  is  relatively 
greater  in  amount  than  the  foetus,  which  it  outweighs.  As  pregnancy 
advances,  the  weight  of  the  foetus  becomes  four  or  five  times  greater  than 
that  of  the  liquor  amnii,  although  the  actual  quantity  of  fluid  increases 
during  the  whole  period  of  gestation.  The  amount  of  fluid  varies  much 
in  diflerent  pregnancies.  Sometimes  there  is  comparatively  little,  while  at 
others  the  quantity  is  immense,  reaching  several  pounds  in  weight,  greatly 
distending  the  uterus,  and  thus,  it  may  be,  producing  difficulty  in  labor. 

Its  Quality. — At  first  the  liquid  is  clear  and  limpid.  As  pregnancy 
advances  it  becomes  more  turbid  and  dense,  from  the  admixture  of 
epithelial  debris  derived  from  the  cutaneous  surface  of  the  foetus.  In 
somo  cases,  without  actual  disease,  it  may  be  dark  green  in  color  and 
thick  and  tenacious  in  consistency.  It  has  a  peculiar  heavy  odor,  and 
it  consists  chemically  of  water  containing  albumen,  with  various  salts, 
princij)ally  pliosphates  and  chlorides. 

Its  Source. — The  source  of  the  liquor  amnii  has  been  much  dis]>uted. 
Some  maintain  that  it  is  derived  chiefly  from  the  foetus — a  view  sufli- 
ciently  disproved  by  the  fact  that  the  liquor  anniii  continues  to  increase 
in  amount  after  the  death  of  the  fijetus.     Burdach  believed  that  it  is 


110  PREGNANCY. 

secreted  by  the  internal  surface  of  the  uterus,  and  arrives  in  the  cavity 
of  the  amnion  by  transudation  through  the  membrane.  Priestley — and 
this  seems  the  most  probable  hypothesis — thinks  that  it  is  secreted  by 
the  epithelial  cells  lining  the  membi-ane,  which  become  distended  Mith 
fluid,  burst,  and  pour  their  contents  into  the  amniotic  cavity. 

Functions  and  Ikes. — The  most  obvious  use  of  the  liquor  amnii  is  to 
afford  a  fluid  medium  in  which  the  foetus  floats,  and  so  is  protected  from 
the  shocks  and  jars  to  which  it  would  otherwise  be  subjected,  and  from 
undue  pressure  upon  the  uterine  walls.  By  distending  the  uterus  it 
saves  the  uterus  from  injury,  ^^'hich  the  movements  of  the  foetus  might 
otherwise  inflict,  and  the  foetus  is  thus  also  enabled  to  change  its  position 
freely.  The  facility  with  which  version  by  external  manipulation  can 
be  effected  depends  entirely  on  the  mobility  of  the  foetus  in  the  fluid 
which  surrounds  it.  Some  have  also  supposed  that  it  prevents  the 
foetus,  in  the  early  months  of  pregnancy,  from  forming  adhesions  to  the 
amnion.  In  labor  it  is  of  great  service  by  lubricating  the  passages,  but 
chiefly  by  forming,  with  the  membranes,  a  fluid  wedge  which  dilates  the 
circle  of  the  os  uteri. 

The  Chorion. — The  chorion  is  the  more  external  of  the  truly  foetal 
membranes,  although  external  to  it  is  the  decidua,  having  a  strictly 
maternal  origin.  It  is  a  perfectly  closed  sac,  its  external  surface,  in 
contact  with  the  decidua,  being  rough  and  shaggy  from  the  development 
of  villi  (Fig.  56),  its  internal-  smooth  and  shining.  As  the  ovum  passes 
along  the  Fallopian  tube  it  receives,  as  we  have  seen,  an  albuminous 
coating,  and  this,  with  the  zona  pellucida,  is  developed  into  a  temporary 
structure,  the  primitive  chorion.  On  its  external  surface  villous  promi- 
nences soon  appear,  which  have  no  ascertained  structure,  and  which 
seem  to  supply  the  early  ovum  with  nutriment  by  enclosmotic  absorp- 
tion from  the  mucous  membrane  of  the  uterus.  This  primitive  chorion, 
ho^vever,  has  not  been  observed  in  the  human  subject,  although  it  may 
be  readily  seen  in  the  ova  of  some  of  the  loM^er  animals,  such  as  the 
dog  and  the  rabbit.  Some  twelve  days  after  conception,  A^hen  the 
blastodermic  membrane  is  formed,  the  true  chorion  appears.  This  is, 
in  fact,  formed  by  the  epiblast  layer  of  the  blastodermic  membrane, 
which  everywhere  lines  the  zona  pellucida  or  primitive  chorion,  and, 
by  pressure,  causes  its  absorption  and  disappearance.  On  the  surface 
of  the  true  chorion  thus  formed,  which  is  now  the  external  envelope 
of  the  ovum,  villi  soon  appear. 

Formation  of  the  Villi. — These  villi  are  hollow^  projections  like  the 
fingers  of  a  glove,  which  are  raised  up  from  the  surface  of  the  chorion 
(the  hollows  looking  into  the  chorionic  cavity),  and  they  cover  the 
whole  external  surface  of  the  ovum,  giving  it  the  peculiar  shaggy 
appearance  observed  in  early  abortions.  They  push  themselves  into 
the  substance  of  the  decidua,  with  wdiich  they  soon  become  so  firmly 
united  that  they  cannot  be  separated  without  laceration.  At  first  they 
are  absolutely  non-vascular,  but  soon  the  allantois,  previously  describee!, 
reaches  the  inner  surface  of  the  chorion  and  spreads  itself  over  the 
whole  of  it.  Each  villus  now  receives  a  separate  flrtery  and  vein,  the 
former  having  a  branch  to  each  of  the  subdivisions  into  which  the  villus 
divides.     These  vessels  are  encased  in  a  fine  sheath  of  the  allantois, 


CONCEPTION  AND   GENERATION.    .  Ill 

which  enters  the  villus  along  with  them  and  forms  a  lining  to  it,  de- 
scribed by  some  as  the  endo-chorion,  the  external  epithelial  membrane 
of  the  villus,  derived  from  the  epiblast  layer  of  the  blastodermic  mem- 
brane, being  called  the  exo-chorion.  The  artery  and  vein  lie  side  by 
side  in  the  centre  of  the  villus  and  anastomose  at  its  extremity ;  each 
villus  thus  having  a  separate  circulation. 

Growth  and  Atrophy  of  the  Villi. — As  soon  as  the  union  of  the 
allantois  with  the  chorion  has  been  effected,  the  villi  grow  very  rapidly, 
give  ofP  branches,  which  in  their  turn  give  off  secondary  branches,  and 
so  form  root-like  processes  of  great  complexity.  In  the  early  months  ' 
of  gestation  they  exist  equally  over  the  whole  surface  of  the  ovum. 
As  pregnancy  advances,  however,  those  which  are  in  contact  with  the 
decidua  reflexa  shrivel  up,  and  by  the  end  of  the  second  month  dis- 
appear, being  no  longer  required  for  the  nutrition  of  the  ovum.  The 
chorion  and  decidua  thus  come  into  close  contact,  being;  united  together 
by  fibrous  shreds,  which  on  microscopic  examination  are  found  to  consist 
of  atrophied  villi.  A  certain  number  of  villi — viz.,  those  which  are  in 
contact  with  the  decidua  serotina — instead  of  dwindling  away,  increase 
greatly  in  size,  and  eventually  develop  into  the  organ  by  which  the 
foetus  is  nourished — the  placenta. 

Form  of  the  Placenta. — This  important  organ  serves  the  purpose  of 
supplying  nutriment  to,  and  aerating  the  blood  of,  the  foetus,  and  on  its 
integrity  the  existence  of  the  foetus  depends.  It  is  met  with  in  all 
mammals,  but  is  very  different  in  form  and  arrangement  in  different 
classes.  Thus,  in  the  sow,  mare,  and  in  the  cetacea  it  is  diffused  over 
the  whole  interior  of  the  uterus ;  in  the  ruminants  it  is  divided  into  a 
number  of  separate  small  masses,  scattered  here  and  there  over  the 
uterine  walls ;  while  in  the  carnivora  and  elephant  it  forms  a  zone  or 
belt  round  the  uterine  cavity.  In  the  human  race,  as  well  as  in  rodentia, 
insectivora,  etc.,  the  placenta  is  in  the  form  of  a  circular  mass,  attached 
generally  to  some  part  of  the  uterus  near  the  orifices  of  one  Fallopian 
tube ;  but  it  may  be  situated  anywhere  in  the  uterine  cavity,  even  over 
the  internal  os  uteri.  As  it  is  expelled  after  delivery  with  the  foetal 
membranes  attached  to  it,  and  as  the  aperture  in  these  corresponds  to 
the  OS  uteri,  we  can  generally  determine  pretty  accurately  the  situation 
in  which  the  placenta  was  placed  by  examining  them  after  expulsion. 
The  maternal  surface  of  the  placenta  is  somewhat  convex,  the  foetal 
concave.  Its  size  varies  greatly  in  different  cases,  and  it  is  usually 
largest  when  the  child  is  big,  but  not  necessarily  so.  Its  average 
diameter  is  from  6  to  8  inches,  its  weight  from  18  to  24  oz.,  but  in 
exceptional  cases  it  has  been  found  to  weigh  several  pounds.  Abnor- 
malities of  form  are  not  very  rare.  Thus,  the  placenta  has  been  found 
to  be  divided  into  distinct  parts — a  form  said  by  Professor  Turner  to 
be  normal  in  certain  genera  of  monkeys ;  or  smaller  su])plenientary 
placentte  {placental  .wx-centarice)  may  exist  round  a  central  mass.  These 
variations  of  shape  are  oriTy  of  importance  in  consequence  of  a  risk  of 
part  of  the  detached  placenta  being  left  in  the  uterus  after  delivery  and 
giving  rise  to  septicaemia  or  secondary  haemorrhage. 

Attachment  of  the  Membranes. — The  foetal  membranes  cover  the  whole 
fjetal  surface  of  the  placenta,  being  reflected  from  its  edges  so  as  to  line 


112  PREGNANCY. 

the  uterine  cavity,  and  being  expelled  with  it  after  delivery.  They  also 
leave  it  at  the  insertion  of  the  cord,  to  which  they  form  a  sheath.  The 
cord  is  generally  attached  near  the  centre  of  the  placenta,  and  from  its 
insertion  the  umbilical  vessels  may  be  seen  dividing  and  radiating  over 
the  whole  foetal  surface. 

lis  3I(dernal  Surface. — The  maternal  surface  is  rough  and  divided  by 
numerous  sulci,  which  are  best  seen  if  the  placenta  is  rendered  convex, 
so  as  to  resemble  its  condition  when  attached  to  the  uterus.  A  careful 
examination  shows  that  a  delicate  membrane  covers  the  entire  maternal 
surface,  unites  the  sulci  together,  and  dips  down  between  them.  This 
is,  in  fact,  the  cellular  layer  of  the  decidua  serotina,  which  is  sejjarated 
and  expelled  with  the  placenta,  the  deeper  layer  remaining  attached  to 
the  uterus.  Numerous  small  openings  may  be  seen  on  the  surface, 
which  are  the  apertures  of  the  veins  torn  off  from  the  uterus,  as  also 
those  of  some  arteries,  Avhich,  after  taking  several  sharp  turns,  open 
suddenly  into  the  substance  of  the  organ. 

J,":  Minute  Structure  of  the  Placenta. — As  regards  the  minute  structure 

■— '  of  the  placenta,  it  is  certain  that  it  consists  essentially  of  two  distinct 
portions — one  foetal,  consisting  of  the  greatly  hypertrophied  chorion 
villi,  with  their  contained  vessels,  which  carry  the  foetal  blood  so  as  to 
bring  it  into  intimate  relation  with  the  maternal  blood,  and  thus  admit 
of  the  necessary  changes  occurring  in  it  connected  with  the  nutrition  of 

/»  the  foetus ;  and  the  other  maternal,  formed  out  of  the  decidua  serotina 
and  the  maternal  blood-vessels.     These  two  portions  are  in  the  human 

^'  female  so  intimately  blended  as  to  form  the  single  deciduous  organ 
which  is  thrown  off  after  delivery.  These  main  facts  are  admitted  by 
all,  but  considerable  differences  of  opinion  still  exist  among  anatomists 
as  to  the  precise  arrangement  of  these  parts.  In  the  following  sketch 
of  the  subject  I  shall  describe  the  views  most  generally  entertained, 
merely  briefly  indicating  the  points  which  are  contested  by  various 
authorities.  /'^ 

Fcetal  Portion  of  the  Placenta. — The  foetal  portion  of  the  placenta 
consists  essentially  of  the  ultimate  ramifications  of  the  chorion  villi, 
which  may  be  seen  on  microscopic  examination  in  the  form  of  club- 
shaped  digitations,  which  are  given  off  at  every  possible  angle  from  the 
stem  of  a  parent  trunk,  just  like  the  branches  of  a  plant.  Within  the 
transparent  walls  of  the  villi  the  capillary  tubes  of  the  contained  vessels 
may  be  seen  lying,  distended  with  blood,  and  presenting  an  appearance 
not  unlike  loops  of  small  intestine.  The  capillaries  are  the  terminal 
ramifications  of  the  umbilical  arteries  and  veins,  which,  after  reaching 
the  site  of  the  placenta,  divide  and  subdivide  until  they  at  last  form  an 
immense  number  of  minute  capillary  vessels,  with  their  convexities  look- 
ing toward  the  maternal  portion  of  the  placenta,  each  terminal  loop 
being  contained  in  one  of  the  digitations  of  the  chorion  villi.  Each 
arterial  twig  is  accompanied  by  a  corresponding  venous  branch,  which 
unites  with  it  to  form  the  terminal  arch  or  loop  (Fig.  59).  The  foetal 
blood  is  carried  through  these  arterial  twigs  to  the  villi,  where  it  comes 
into  intimate  contact  with  the  maternal  blood,  in  consequence  of  the 
anatomical  arrangements  presently  to  be  described  ;  but  the  two  do  not 
directly  mix,  as  the  older  physiologists  believed,  for  none  of  the  mater- 


CONCEPTION  ANT)   GENERATION. 


ri3 


nal  blood  escapes  when  the  umbilical  cord  is  cut,  nor  can  the  minutest 
injections  through  the  foetal  vessels  be  made  to  pass  into  the  maternal 


Placental  Villus,  greatly  magnified.    (After  Joulin.) 

1,  2.  Placental  vessels,  forming  terminal  loops.    3.  Chorion  tissue,  forming  external  walls  of  villus. 

4.  Tissue  surrounding  vessels. 

vascular  system,  or  vice  versa.     In  addition  to  the  looped  terminations  of 
the  umbilical  vessels,  Farre  and  Schroeder  van  der  Kolk  have  described 

Fig.  60. 


a.  Terminal  villus  of  foetal  tuft,  minutely  irjjected.     h.  Its  nueloiltod  non-vascular  sheath.     (After  Tarre.) 

another  set  of  capillary  vessels  in  connection  with  each  villus  (Fisi;.  00). 
This  ajnsists  of  a  very  fine  network  covering  each  villus,  and  very  differ- 


114 


PREGNANCY. 


ent  in  appearance  from  the  convoluted  vessels  lying  in  its  interior,  which 
are  the  only  ones  which  have  been  usually  described.  Dr.  Farre  T)elieves 
that  these  vessels  only  exist  in  the  early  months  of  pregnancy,  and  that 
they  disappear  as  pregnancy  advances,  Priestley  ^  suggests  that  they  may 
not  be  vessels  at  all,  but  lymphatics,  which  may  possibly  absorb  nutrient 
material  from  the  mother's  blood  and  throw  it  into  the  foetal  vascular 
system.  The  existence  of  lymphatics,  or  nerves,  in  the  placenta,  how- 
ever, has  never  been  demonstrated,  and  they  are  believed  not  to  exist. 

Maternal  Portion  of  the  Placenta. — As  generally  described,  the  mater- 
nal portion  of  the  placenta  consists  of  large  cavities,  or  of  a  single  large 
cavity,  which  contains  the  maternal  blood,  and  into  which  the  villi  of 
the  chorion  penetrate  (Fig.  61).  Into  this  maternal  part  of  the  viscus 
the  curling  arteries  of  the  uterus  pour  their  blood,  which  is  collected 
from  it  by  the  uterine  sinuses.     The  villi  of  the  chorion,  therefore,  are 

Fig.  61. 


Diagram  representing  a  Vertical  Section  of  the  Placenta.    (After  Dalton.) 


Chiiridii.     h,  b.  Decidua. 


Orifices  of  iitprine  snuises. 


suspended  in  a  sac  filled  with  maternal  blood,  which  penetnites  freelv 
between  them,  and  with  which  they  are  brought  into  very  intimate  con- 
tact. 

Theory  of  Beid.—Dr.  John  Keid  believed  that  only  the  delicate  inter- 
nal lining  of  the  maternal  vessels  entered  the  substance  of  the  ])lacenta 
to  form  "the  sac  just  spoken  of.  Into  this  the  villi  project,  i)ushing 
before  them  the  membrane  forming  the  limiting  wall  of  the  i)lacental 
sinuses,  each  of  them  in  this  way  receiving  an  investment,  just  as  the 
fingers  of  a  hand  are  covered  by  a  glove  (Fig.  62). 

Theory  of  Goodsir. —Schroeder  van  der  Kolk  and  Goodsir  (Fig.  63) 
were  of  opinion  that  not  only  were  the  maternal  blood-vessels  continued 
into  the  substance  of  the  placenta,  but  also  the  processes  of  the  decidua, 
which  accompanied  the  vessels  and  were  prolonged  over  each  villus,  so 
as  to  separate  it  from  the  limiting  membrane  of  the  maternal  sinuses. 

^  The  Gravid  Uterus,  p.  52. 


CONCEPTION  AND   GENERATION. 


115 


Each  villus  would  thus  be  covered  by  two  layers  of  fine  tissue — one 
from  the  internal  lining  membrane  of  the  maternal  blood-vessels,  the 
other  from  the  epithelial  cells  of  the  decidua. 

Theory  of  Turner. — Turner,  whose  valuable  researches  on  the  com- 
parative anatomy  of  the  placenta  have  thrown  much  light  on  its  struc- 
ture, points  out  that  the  placentae  of  all  animals  are  formed  on  the  same 


Fig.  62. 


Fig.  63. 


C--~. 


Diagram  illustrating  the  mode  in  which  a  Placen- 
tal Villus  derives  a  Covering  from  the  Vascular 
System  of  the  Mother.    (After  Priestley.) 

a.  Villus  having  three  termiDal  digitations  projecting  into 
6.  Cavity  of  the  mother's  vessel,  e.  Dotted  lines  repre- 
senting coat  of  vessel. 


The  Extremity  of  a  Placental  Villus. 
(After  Goodsir.) 

a.  External  membrane  of  villus  (the  lining 
membrane  of  vascular  system  of  Weber). 

6.  External  cells  of  villus  derived  from 
decidua. 

c.  c.  Nuclei  of  ditto. 

d.  The  space  between  the  maternal  and 
foetal  portions  of  villus. 

e.  Its  internal  membrane. 
/.  Its  internal  cells. 

g.  The  loop  of  umbilical  vessels. 


fundamental  type,^  in  which  t\\e  foetal  portion  consists  of  a  smooth,  plane- 
surfaced  vascular  membrane  covered  with  pavement  epithelium,  w^iich 
is  brought  into  contact  with  the  maternal  jportion,  consisting  of  a  smooth, 
plane-surfaced  vascular  membrane  covered  with  columnar  epithelium. 
The  foetal  capillaries  are  separated  from  the  maternal  capillaries  only  by 
two  opposed  layers  of  epithelium.  In  various  animals  the  placentae  are 
more  or  less  specialized  from  the  generalized  form,  in  some  to  a  much 
greater  extent  than  others.  In  the  human  placenta  the  maternal  vessels! 
have  lost  their  normal  cylindrical  form,  and  are  dilated  into  a  system  of ': 
freely  intercommunicating  placental  sinuses,  which  are,  in  fact,  maternal 
capillaries  enormously  enlarged,  with  their  walls  so  expanded  and  thinned  ;j 
out  that  they  cannot  be  recognized  as  a  distinct  layer  limiting  the  sinusal 
Each  foetal  chorion  villus  projecting  into  these  sinuses  is  covered  with  a 
layer  of  cells  distinct  from  those  of  the  epithelial  layer  of  the  villus, 
and  readily  stripped  from  it.  These  are  maternal  in  their  origin,  and 
are  derived  from  the  decidua,  which  sends  prolongations  of  its  tissue 
into  the  placenta.  These  cells,  he  believes,  form  a  secreting  epithelium 
whi(;h  separates  from  the  maternal  blood  a  secretion  for  the  nourishment 
of  the  ffjetus,  which  is,  in  its  turn,  absorbed  by  the  villi  of  the  chorion. 
Theory  of  Ercolani. — A  view  not  very  dissimilar  to  this  has  been 
advanced  by  Professor  Ercolani  of  Bologna,  who  maintains  that  the 
niat(;rnal  portion  of  the  placenta  is  a  new  formation,  strictly  glandular, 
and  not  vascular,  in  its  structure.  It  is  formed,  he  thinks,  by  the  .sub- 
mucous fX)imective  tissue  of  the  decidua  scrotiiia,  and  it  (lii)s  down  into 
the  placenta  and  forms  a  slieath  to  each  of  the  chorion  villi,  which  it 
'  Introducliiin  to  Unman  Anulomy,  Part  2. 


116  PREGNANCY. 

separates  from  the  maternal  blood.  This  new  glandular  structure  he 
describes  as  secreting  a  fluid,  termed  the  "  uterine  milk,"  which  is  ab- 
sorbed by  the  villi  of  the  chorion,  just  as  the  mother's  milk  is  absorbed 
by  the  villi  of  the  intestines,  and  it  is  with  this  fluid  alone  that  the 
chorion  villi  are  in  direct  contact.  The  sheath  thus  formed  to  each  villus 
is  doubtless  analogous  to  the  layer  of  cells  which  Goodsir  described  as 
encasing  each  villus,  but  is  attributed  to  a  new  structure  formed  after 
conception. 

Theory  of  Braxton  Hicks. — The  existence  of  the  maternal  sinus  sys- 
tem in  the  placenta  is  altogether  denied  by  anatomists  of  eminence  whose 
views  are  worthy  of  careful  consideration.  Prominent  among  these  is 
Braxton  Hicks,^  who  has  written  an  elaborate  paper  on  the  subject.  He 
holds  that  there  is  no  evidence  to  prove  that  the  maternal  blood  is  poured 
out  into  a  cavity  in  which  the  chorion  villi  float,  and  he  believes  that 
the  curling  arteries,  instead  of  entering  the  so-called  maternal  portion 
of  the  placenta,  terminate  in  the  decidua  serotina.  The  hypertrophied 
chorion  villi  at  the  site  of  the  placenta  are  firmly  attached  to  the  decidual 
surface,  into  which  their  tips  are  imbedded.  The  line  of  junction  be- 
tween the  decidual  reflexa  and  serotina  forms  a  circumferential  maro;in 
to,  and  limits,  the  placenta.  The  arrangement  of  the  foetal  portion  of 
the  placenta  on  this  view  is  very  similar  to  that  generally  described,  but 
the  villi  are  not  surrounded  by  maternal  blood  at  all,  and  nothing  exists 
between  them,  unless  it  be  a  small  quantity  of  serous  fluid.  The  change 
in  the  fcetal  blood  is  effected  by  endosmosis,  and  Hicks  suggests  that  the 
follicles  of  the  decidua  may  secrete  a  fluid,  which  is  poured  into  the 
intervillous  spaces  for  absorption  by  the  villi. 

Functions  of  the  Placenta. — It  will  thus  be  seen  that  anatomists  of 
repute  are  still  undecided  as  to  important  points  in  the  minute  anatomy 
of  the  placenta,  which  further  investigation  will  doubtless  clear  up. 
The  main  functions  of  the  organ  are,  however,  sufficiently  clear.  During 
the  entire  period  of  its  existence  it  fills  the  important  office  of  both 
stomach  and  lungs  to  the  foetus.  Whatever  view  of  the  arrangement 
of  the  maternal  blood-vessels  be  taken,  it  is  certain  that  the  foetal  blood 
is  propelled  by  the  pulsations  of  the  foetal  heart  into  the  numberless  villi 
of  the  choi'ion,  where  it  is  brought  into  very  intimate  relation  with  the 
mother's  blood,  gives  off  its  carbonic  acid,  absorbs  oxygen,  and  passes 
back  to  the  foetus,  through  the  umbilical  vein,  in  a  fit  state  for  circula- 
tion. The  mode  of  respiration,  therefore,  in  the  foetus  is  analogous  to 
that  in  fishes,  the  chorion  villi  representing  the  gills,  the  maternal  blood 
the  water  in  which  they  float.  JSTutrition  is  also  effected  in  the  organ, 
and,  by  absorption  through  the  chorion  villi,  the  pabulum  for  the 
nourishment  of  the  foetus  is  taken  up.  It  also  probably  serves  as  an 
emunctory  for  the  products  of  excretion  in  the  foetus.  Picard  found 
that  the  blood  in  the  placenta  contained  an  appreciably  larger  quantity 
of  urea  than  that  in  other  parts  of  the  body,  this  urea  probably  being 
derived  from  the  foetus.  Claude  Bernard  also  attributed  to  it  a  glyco- 
genic function,^  supposing  it  to  take  the  place  of  the  foetal  liver  until 
that  organ  was  sufficiently  developed. 

Dcf/cncrative  Changes  Previous  to  Expulsion. — Finally,  we  find  that 

^  Obst.  Trans.,  vol.  xiv.  ^  Acad,  des  Sciences,  April,  1859. 


CONCEPTION  AND   GENERATION.  117 

the  temporary  character  of  the  placenta  is  indicated  by  certain  degenera- 
tive changes  which  take  place  in  it  previous  to  expulsion.  These  consist 
chiefly  in  the  deposit  of  calcareous  patches  on  its  uterine  surface,  and  in 
fatty  degeneration  of  the  villi  and  of  the  decidual  layer  between  the 
placenta  and  the  uterus.  If  this  degeneration  be  carried  to  excess,  as  is 
not  unfrequently  the  case,  the  foetus  may  perish  from  want  of  a  sufficient 
number  of  healthy  villi  through  which  its  respiration  and  nutrition  may 
be  effected. 

Umhilical  Cord. — The  umbilical  cord  is  the  channel  of  communication 
between  the  foetus  and  placenta,  being  attached  to  the  former  at  the  um- 
bilicus, to  the  latter  generally  near  its  centre,  but  sometimes,  as  in  the 
battledore  placenta,  at  its  edge.  It  varies  much  in  length,  measuring 
on  an  average  from  18  to  24  inches,  but  in  exceptional  cases  being  found 
as  long  as  50  or  60,  and  as  short  as  5  or  6,  inches. 

When  fully  formed  it  consists  of  an  external  membranous  layer  formed 
of  the  amnion,  two  umbilical  arteries,  one  umbilical  vein,  and  a  con- 
siderable quantity  of  a  transparent  gelatinous  substance  surrounding  the 
vessels,  called  Wharton's  jelly,  which  is  contained  in  a  fine  network  of 
fibres,  and  is  formed  out  of  the  tissue  of  the  allantois.  At  an  early 
period  of  pregnancy,  in  addition  to  these  structures,  the  cord  contains 
the  pedicle  of  the  umbilical  vesicle,  with  the  omphalo-mesenteric  vessels 
ramifying  on  it,  and  two  umbilical  veins,  one  of  which  soon  atrophies 
and  disappears.  No  nerves  or  lymphatics  have  been  satisfactorily  demon- 
strated in  the  cord,  although  such  have  been  described  as  existing.  The 
vessels  of  the  cord  are  at  first  straight  in  their  course,  but  shortly  they 
become  greatly  twisted,  the  arteries  being  external  to  the  vein,  and  in 
nine  cases  out  of  ten  the  twist  is  from  left  to  right.  Various  explana- 
tions have  been  given  of  this  peculiarity,  none  of  them  entirely  satis- 
factory. Tyler  Smith  attributed  it  to  the  movements  of  the  foetus 
twisting  the  cord,  its  attachment  to  the  placenta  being  a  fixed  point ; 
this  would  not,  however,  account  for  the  frequency  with  which  the 
spiral  turns  occur  in  one  direction.  Mr.  John  Simpson  attributed  it  to 
the  greater  pressure  of  the  blood  through  the  right  hypogastric  artery, 
on  account  of  that  vessel  having  a  more  direct  relation  to  the  aorta  than 
the  left.  The  umbilical  arteries  give  off  no  branches,  and  the  vein  con- 
tains no  valves,  nor  can  any  vasa  vasorum  be  detected  in  their  coats 
after  they  have  left  the  umbilicus.  The  umbilical  arteries  increase  in 
size  after  they  leave  the  cord  to  divide  on  the  surface  of  the  placenta. 
This  is  the  only  example  in  the  body  in  which  arteries  are  larger  near 
their  terminations  than  their  origin,  and  the  object  of  this  arrangement 
is  probably  to  effect  a  retardation  of  the  current  of  the  blood  distrib- 
uted to  the  placenta.  Tlie  tortuous  course  of  the  vein  jirobably  com- 
pensates for  the  absence  of  valves,  and  moderates  the  flow  of  blood 
through  it.  Distinct  knots  are  not  unfre<)uently  observed  in  the  cord, 
l)ut  they  rarely  have  the  effect  of  obstructing  the  circulation  through  it. 
They  no  doubt  form  when  the  foetus  is  very  small.  They  may  some- 
times also  he  produced  in  labor  by  the  child  being  propelled  through  a 
coil  of  the  cord  lying  circnlarly  round  th(!  os  uteri.  Tlic  so-called  false 
knots  are  merely  accidental  nodosities  due  to  local  enlargements  of  the 
vessels. 


118  PREGNANCY. 


CHAPTER   II. 
THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS. 

It  is  obviously  impossible  to  attempt  anything  like  a  full  account  of 
the  development  of  the  various  foetal  structures,  or  of  their  growth,  dur- 
ing intra-uterine  life.  To  do  so  would  lead  us  far  beyond  the  scope  of 
this  work,  and  would  involve  a  study  of  complex  details  only  suitable 
in  a  treatise  on  embryology.  It  is  of  importance,  however,  that  the 
practitioner  should  have  it  in  his  power  to  cletermine  approximately  the 
age  of  the  foetus  in  abortions  or  premature  labors,  and  for  this  purpose 
it  is  necessary  to  describe  briefly  the  appearance  of  the  foetus  at  various 
stages  of  its  growth. 

Appearance  of  the  Foetus  at  Various  Stages  of  Development. — 1st 
Month  :  The  foetus  in  the  first  month  of  gestation  is  a  minute  gelatinous 
and  semi-transparent  mass,  of  a  grayish  color,  in  which  no  definite 
structure  can  be  made  out,  and  in  which  no  head  or  extremities  can  be 
seen.  It  is  rarely  to  be  detected  in  abortions,  being  lost  in  surrounding 
blood-clots.  In  the  few  examples  which  have  been  carefully  examined 
it  did  not  measure  more  than  a  line  in  length.  It  is,  however,  already 
surrounded  by  the  amnion,  and  the  pedicle  of  the  umbilical  vesicle  can 
be  traced  into  the  unclosed  abdominal  cavity. 

2d  Month  :  The  embryo  becomes  more  distinctly  apparent,  and  is 
curved  on  itself,  weighing  about  G2  grains,  and  measuring  6  to  8  lines 
in  length.  The  head  and  extremities  are  distinctly  visible,  the  latter  in 
the  form  of  rudimentary  projections  from  the  body.  The  eyes  are  to  be 
seen  as  small  black  spots  on  the  side  of  the  head.  The  spinal  column  is 
divided  into  separate  vertebrae.  The  independent  circulatory  system  of 
the  foetus  is  now  beginning  to  form,  the  heart  consisting  of  only  one 
ventricle  and  one  auricle,  from  the  former  of  which  both  the  aorta  and 
pulmonary  arteries  arise.  On  either  side  of  the  vertebral  colunni,  reach- 
ing from  the  heart  to  the  pelvis,  are  two  large  glandular  structures,  the 
corpora.  Wolfflana,  which  consist  of  a  series  of  convoluted  tubes  open- 
ing into  an  excretory  duct  running  along  their  external  borders,  and 
connected  below  with  the  common  cloaca  of  tlie  genito-urinary  and 
digestive  tracts.  They  seem  to  act  as  secreting  glands,  and  fulfil  the 
functions  of  the  kidneys  before  they  are  formed.  Toward  tlie  end  of  the 
.  second  month  they  atrophy  and  disappear,  and  the  only  trace  of  them  in 
the  foetus  at  term  is  to  be  found  in  the  parovarium  lying  between  the 
folds  of  the  broad  ligaments.  At  this  stage  of  development  there  are 
met  Avith  in  the  human  embryo,  as  in  that  of  all  mammals,  four  trans- 
verse fissures  opening  into  the  pharynx,  Avliich  are  analogous  to  the  per- 
manent branchise  of  fishes.  Their  vascular  supply  is  also  similar,  as  the 
aorta  at  this  time  gives  off  four  branches  on  each  side,  each  of  which 
forms  a  branchial  arch,  and  these  afterward  unite  to  form  the  descend- 
ing aorta.     By  the  end  of  the  sixth  week  these,  as  well  as  the  transverse 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        119 

fissures  to  which  they  are  distributed,  disappear.  By  the  end  of  the 
second  month  the  kidneys  and  supra-renal  capsules  are  forming,  and  the 
single  ventricle  is  divided  into  two  by  the  growth  of  the  inter-ventric- 
ular septum.  The  umbilical  cord  is  quite  straight,  and  is  inserted  into 
the  lower  part  of  the  abdomen.  Centres  of  ossification  are  showing 
themselves  in  the  inferior  maxillary  bones  and  the  clavicle. 

3d  Month  :  The  embryo  weighs  from  70  to  300  grains,  and  measures    | 
from  2^  to  3|-  inches  in  length.     The  forearm  is  well  formed,  and  the  J 
first  ti^es  of  the  fingers  can  be  made  out.    The  head  is  large  in  propor- 
tion to  the  rest  of  the  body,  and  the  eyes  are  prominent.    The  umbilical 
vesicle  and  allantois  have  disappeared,  the  greater  portion  of  the  chorion    i 
villi  have  atrophied,  and  the  placenta  is  distinctly  formed.  -: 

4th  Month  :  The  weight  is  from  4  to  6  oz.,  and  the  length  about  6    j 
inches.     The  convolutions  of  the  brain  are  beginning  to  develop.     The  " 
sex  of  the  child  can  now  be  ascertained  on  inspection.     The  muscles  are 
sufficiently  formed  to  produce  distinct  movements  of  the  limbs.     Ossifi- 
cation is  extending,  and  can  be  traced  in  the  occipital  and  frontal  bones 
and  in  the  mastoid  processes.     The  sexual  organs  are  differentiated. 

5th  Month  :  Weight,  about  10  oz. ;  lengthy  9  or  10  inches.     Hair  is  J. 
observed  covering  the  head,  which  forms  about  one-third  of  the  length 
of  the  whole  foetus.     The  nails  are  beginning  to  form,  and  ossification  i 
has  commenced  in  the  ischium.  "~ 

6th  Month:  Weight,  about  1   lb.;  length,  11   to  121  inches.     The  I 
hair  is  darker.     The  eyelids  are  closed,  and  the  membrana  pupillaris 
exists ;  eyelashes  have  now  been  formed.     Some  fat  is  deposited  under 
the  skin.     The  testicles  are  still  in  the  abdominal  cavity.     The  clitoris 
is  prominent.     The  pubic  bones  have  begun  to  ossify. 

7th  Month  :  Weight,  from  3  to  4  lbs. ;  length,  13  to  15  inches.  The 
skin  is  covered  with  unctuous,  sebaceous  matter,  and  there  is  a  more 
considerable  deposit  of  subcutaneous  fat.  The  eyelids  are  open.  The 
testicles  have  descended  into  the  scrotum. 

8th  Month  :  AVeight,  from  4  to  5  lbs. ;  length,  16  to  18  inches,  and 
the  foetus  seems  now  to  grow  in  thickness  rather  than  in  length.  The 
nails  are  completely  developed.  The  membrana  pupillaris  has  disap- 
peared. 

Foetus  at  Term. — At  the  completion  of  pregnancy  the  foetus  weighs  on  i 
an  average  6|-  lbs.  and  measures  about  20  inches  in  length.  These  J 
averages  are,  however,  liable  to  great  variation.  Remarkable  histories 
are  given  by  many  writers  of  foetuses  of  extraordinary  M^eight,  which 
have  been  probably  greatly  exaggerated.  Out  of  3000  children  deliv- 
ered under  the  care  ofCazeaux  at  various  charities,  one  only  weighed  10 
lbs.  There  are,  however,  several  carefully  recorded  instances  of  weight 
far  exceeding  this,  but  they  are  undoubtedly  much  more  uncommon 
than  is  generally  sup]iosod.  Dr.  Ramsbottoni  mentions  a  fa>tus  weigh- 
ing 16i  li)s.  ;  Cazcaux  tells  us  of  one  whicli  he  delivered  by  turning 
whicli  weighed  18  lbs.  and  measured  2  feet  1-^-  inches,  and  the  birth  of 
one  weighing  21  lbs.  has  been  recently  recorded.^  Such  overgrown  chil- 
dren are  almost  invariably  stilll)orn.['] 

'  Bril.  Med.  Jonrn.,  Fel).  1,  ].S7!I. 

['■^  Probalily  the   l;ir;;(.st   l.r'tiis  nn    rccdnl  \v;is  tliiit   nf  Mrs.  ('n])lain  IJ.ites,  tlie  Nova 


120  PREGNANCY. 

The  average  size  of  male  children  at  birth,  as  in  after-life,  is  some- 
what greaterthan  that  of  female.  Thus,  Simpson  ^  found  that  out  of  100 
cases  the  male  children  averaged  10  oz.  more  in  weight  than  the  female, 
and  half  an  inch  more  in  length. 

Vernix  Cascosa. — A  new-born  child  at  term  is  generally  covered  to  a 
greater  or  less  extent  with  a  greasy,  unctuous  material,  the  vernix 
caseosa,  which  is  formed  of  epithelial  scales  and  the  secretion  of  the 
sebaceous  glands,  and  which  is  said  to  be  of  use  in  labor  by  lubricating 
the  surface  of  the  child.  The  head  is  generally  covered  with  long  dark 
hair,  which  frequently  falls  otf  or  changes  in  color  shortly  after  birtli. 
Dr.  Wiltshire^  has  called  attention  to  an  old  observation,  that  the  eyes 
of  all  new-born  children  are  of  a  peculiar  dark  steel-gray  color,  and 
that  they  do  not  acquire  their  permanent  tint  until  some  time  after 
birth.  The  umbilical  cord  is  generally  inserted  below  the  centre  of  the 
body. 

Anatomy  of  the  Foetal  Head. — The  most  important  part  of  the  foetus 
from  an  obstetrical  point  of  view  is  the  head,  which  requires  a  separate 
study,  as  it  is  the  usual  presenting  part,  and  the  facility  of  the  labor 
depends  on  its  accurate  adaptation  to  the  maternal  passages. 

The  chief  anatomical  peculiarity  of  interest  in  the  head  of  the  foetus  at 
term  is  that  the  bones  of  the  skull,  especially  of  its  vertex — which,  in 
the  vast  majority  of  cases,  has  to  pass  first  through  the  pelvis — are  not 
firmly  ossified  as  in  adult  life,  but  are.  joined  loosely  together  by  mem- 
j  brane  or  cartilage.  The  result  of  this  is,  that  the  skull  is  capable  of 
being  moulded  and  altered  in  form  to  a  very  considerable  extent  by  the 
pressure  to  which  it  is  subjected,  and  thus  its  passage  through  the  pelvis 
is  very  greatly  facilitated.  This,  however,  is  chiefly  the  case  with  the 
cranium  proper,  the  bones  of  the  face  and  of  the  base  of  the  skull  being 
more  firmly  united.  By  this  means  the  delicate  structures  at  the  base 
of  the  braiii  are  protected  from  pressure,  Avhile  the  change  of  form  which 
the  skull  undergoes  during  labor  implicates  a  portion  of  the  skull  where 
pressure  on  the  cranial  contents  is  least  likely  to  be  injurious. 

The  divisions  between  the  bones  of  the  cranium  are  further  of  obstet- 
ric importance  in  enabling  us  to  detect  the  precise  position  of  the  head 
during  labor,  and  an  accurate  knowledge  of  them  is  therefore  essential  to 
the  obstetrician. 

The  Sidiires  and  Fontanelles. — We  talk  of  them  as  suture.'i  audfonta- 
nelles,  the  former  being  the  lines  of  junction  between  the  separate  bones, 
which  overlap  each  other  to  a  greater  or  less  extent  during  labor ;  the 
latter,  membranous  interspaces  where  the  sutures  join  each  other. 

The  principal  sutures  are :  1st,  the  mc/ittal,  which  separates  the  two 
parietal  bones,  and  extends  longitudinally  backward  along  the  vertex 

Scotia  giantess,  a  woman  of  7  ft.  9  in.,  whose  husband  is  also  of  gigantic  build,  reaching 
7  ft.  7  in.  in  height  This  child,  born  in  Ohio,  was  their  second,  and  was  lost  in  its 
birth,  as  no  forceps  could  be  procured  of  sufficient  size  to  grasp  the  head.  The  fo?tus 
weighed  23J  lbs.  and  was  30  in.  in  lengtli.  Their  first  infant  weighed  18  lbs.  Dr. 
George  Eddowes  of  Crewe,  England,  delivered  a  woman,  on  Nov.  12,  1884,  of  a  male 
child  weighing  20  lbs.  2  oz.  It  matured  23  inclies  in  length  and  14A  inches  around 
the  chest  {Lancet,  Nov.  22,  1884,  p.  941).  We  have  had  children  born  in  this  city 
(Philadelphia)  at  maturity  and  live  that  Aveighed  but  one  ))ound.  The  well-remem- 
bered "  Pincus  babv  "  weighed  a  pound  and  an  ounce.— Ed.] 

1  Selected  Ohst.  Works,  p.  327.  =  Lmicel,  February  11,  1871. 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        121 

of  the  head ;  2d,  the  frontal,  which  is  a  continuation  of  the  sagittal, 
and  divides  the  two  halves  of  the  frontal  bone,  at  this  time  separate 
from  each  other ;  3d,  the  coronal,  which  separates  the  frontal  from  the 
parietal  bones,  and  extends  from  the  squamous  portion  of  the  temporal 
bone  across  the  head  to  a  corresponding  point  on  the  opposite  side ;  and 
4tli,  the  lambdoidal,  which  receives  its  name  from  its  resemblance  to  the 
Greek  letter  A,  and  separates  the  occipital  from  the  parietal  bones  on 
either  side.  The  fontanelles  (Fig.  64)  are  the  membranous  interspaces 
where  the  sutures  join — the  aMeriqriSind  larger  being  lozenge-shaped, 
and  formed  by  the  junction  of  the  frontal,  sagittal,  and  two  halves  of  the  jl  ^ 
coronal  sutures.  It  will  be  well  to  note  that  there  are,  therefore,  four  "^y^ 
lines  of  sutures  running  into  it,  and  four  angles,  of  which  the  anterior, 
formed  by  the  frontal  suture,  is  most  elongated  and  well  marked.  The 
posterior  fontanelle  (Fig.  65)  is  formed  by  the  junction  of  the  sagittal 
suture  with  the  two  legs  of  the  lambdoidal.  It  is  therefore  triangular  "  y 
in  shape,  with  three  lines  of  suture  entering  it  in  three  angles,  and  is 


Fig.  64. 


Anterior  and  Posterior 
Fontanelles. 


Bi-parietal  Diameter   "^igfittal  anii  Lambdoidal 
Sutuicb,  with  Postcrioi  rontanclle. 


much  smaller  than  the  anterior  fontanelle,  forming  merely  a  depression 
into  which  the  tip  of  the  finger  can  be  placed,  while  the  latter  is  a  hollow 
as  big  as  a  shilling,  or  even  larger.  As  it  is  the  posterior  fontanelle 
which  is  generally  lowest,  and  the  one  most  commonly  felt  during  labor, 
it  is  important  for  the  student  to  familiarize  himself  with  it,  and  he 
should  lose  no  opportunity  of  studying  the  sensations  imparted  to  the 
finger  by  the  sutures  and  fontanelles  in  the  head  of  the  child  after 
birth. 

The  Diameters  of  the  Foetal  Skull. — For  the  pur])ose  of  understanding 
the  mechanism  of  labor  we  must  study  the  measurements  of  tlic  fetal 
head  in  relation  to  the  cavity  through  wliicli  it  has  to  pass.  Thoy  are 
taken  from  corresponding  yxnutn  opposite  to  (sach  other,  and  arc  known 
as  the  diameters  of  the  skull  (Fig.  66).  Those  of  most  importance  are  : 
1st.  The  o(Tij)ito-menta.l,  from  tlie  occi|)ital  ])rotul)erance  to  the  point 
of  tlie  chin,  5.25"  to  5.50''.  2d.  The  oreipifo-froiitdl,  from  the  occiput 
to  the  centre  of  tlie  forehead,  4.50"  to  5".     'M.  The  ^iih-occij>il(>-hrrf/- 


122 


PREGNANCY. 


Fig.  66. 


1  and  2.  Occipito-froutal  diameter. 

3  and  4.  Occipito-niental. 

5  and  6.  Cervico-bregmatic 

7  and  8.  Fronto-meutal. 


matic,  from  a  point  midway  between  the  o('('i})ital  protuberance  and  the 
margin  of  the  foramen  magnum  to  the  centre  of  the  anterior  fontanelle, 
3.25".     4th.  The   cervico-bregmatic,  from  the  anterior  margin  of  the 

foramen  magnum  to  the  centre 
of  the  anterior  fontanelle,  3.75". 
5th.  Transvertie,  or  bi-pariekd,  be- 
tween the  parietal  protuberances, 
3.75"  to  4".  6th.  Bi-temporal,  be- 
tween the  ears,  3.50".  7th.  Fronio- 
mental,  from  the  apex  of  the  fore- 
head to  the  chin,  3.25". 

Alteration  of  Diameters  by  Com- 
pression and  Moulding  during  La- 
bor.— The  length  of  these  respective 
diameters,  as  given  by  different  wri- 
ters, differs  considerably,  a  fact  to  be 
explained  by  the  measurements  hav- 
ing been  taken  at  different  times — 
by  some  just  after  birth,  when  the 
head  was  altered  in  shape  by  the 
moulding  it  had  undergone ;  by  others  when  this  had  either  been  slight 
or  after  the  head  had  recovered  its  normal  shape.  The  above  measure- 
ments may  be  taken  as  the  average  of  those  of  the  normally  shaped  head, 
and  it  is  to  be  noted  that  the  first  two  are  most  apt  to  be  modified  during 
labor.  The  amount  of  compression  and  moulding  to  which  the  head  may 
be  subjected  without  proving  fatal  to  the  foetus  is  not  certainly  known, 
but  it  is  doubtless  very  considerable.  Some  interesting  examples  of  the 
extent  to  which  the  head  may  be  altered  in  shape  in  difficult  labors  have 
been  given  by  Barnes,^  who  has  shown  by  tracings  of  the  shape  of  the  head 
taken  immediately  after  delivery  that  in  protracted  labor  the  occipito- 
mental and  occipito-frontal  diameters  may  be  increased  more  than  an 
inch  in  length,  while  lateral  compression  may  diminish  the  bi-parietal 
diameter  to  the  same  length  as  the  inter-auricular.  The  foetal  head  is 
movable  on  the  vertical  "column  to  the  extent  of  a  quarter  of  a  circle ; 
and  it  seems  probable  that  the  laxity  of  the  ligaments  admits  with 
impunity  a  greater  circular  movement  than  Avould  be  possible  in  the 
adult. 

Influence  of  Sex  and  Race  on  the  Fo'tal  Head. — On  taking  the  aver- 
age of  a  large  number  of  measurements,  it  is  found  that  the  heads  of 
male  children  are  larger  and  more  firmly  ossified  than  those  of  females, 
the  former  averaging  about  half  an  inch  more  in  circumference.  Sir 
James  Simpson  attributed  great  importance  to  this  fact,  and  believed 
that  it  was  sufficient  to  account  for  the  larger  jiroportion  of  stillbirths 
in  male  than  in  female  children,  as  well  as  for  the  greater  difficulty  of 
labor  and  the  increased  maternal  mortality  that  are  found  to  attend  on 
male  births.  His  well-known  paper  on  this  subject,  which  has  given 
rise  to  much  controversy,  is  full  of  the  most  elaborate  details ;  and  so 
great  did  he  believe  the  fo?tal  influence  to  be  that  he  calculated  that 
between  the  years  1834  and  1837  there  were  lost  in  Great  Britain,  as 

^  Obtit.  Trans.,  vol.  vii. 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        123 

a  consequence  of  the  slightly  larger  size  of  the  male  than  of  the 
female  head  at  birth,  about  50,000  lives,  including  those  of  about 
46,000  or  47,000  infants,  and  of  between  3000  and  4000  mothers  who 
died  in  childbed.^  It  is  probable  that  race  and  other  conditions,  such 
as  civilization  and  intellectual  culture,  have  considerable  influence  on 
the  size  of  the  foetal  skull,  but  we  are  not  in  possession  of  sufficiently 
accurate  data  to  justify  any  very  positive  opinion  on  these  points. 

Position  of  the  Foetus  in  Utero. — In  the  very  large  majority  of  cases 
the  foetus  lies  in  utero  with  head  downward,  and  is  so  placed  as  to  be 
adapted  in  the  most  convenient  way  to  the  cavity  in  which  it  is  placed. 
The  uterine  cavity  is  most  roomy  at  the  fundus,  and  narrowest  at  the 
cervix,  and  the  greatest  bulk  of  the  foetus  is  at  the  breech,  so  that  the 
largest  part  of  the  child  usually  lies  in  the  part  of  the  uterus  best 
adapted  to  contain  it.  The  various  parts  of  the  child's  body  are  further 
so  placed,  in  regard  to  each  other,  as  to  take  up  the  least  possible 
amount  of  space.  (See  frontispiece.)  The  body  is  bent  so  that  the 
spine  is  curved  with  its  convexity  outward,  this  curvature  existing  from 
the  earliest  period  of  development ;  the  chin  is  flexed  on  the  sternum ; 
the  forearms  are  flexed  on  the  arms,  and  lie  close  together  on  the  front 
of  the  chest ;  the  legs  are  flexed  on  the  thighs,  and  the  thighs  drawn  up 
on  the  abdomen ;  the  feet  are  drawn  up  toward  the  legs ;  the  umbilical 
cord  is  generally  placed  out  of  reach  of  injurious  pressure,  in  the  space 
between  the  arms  and  the  thighs.  Variations  from  this  attitude,  how- 
ever, are  not  uncommon,  and  are  not,  as  a  rule,  of  much  consequence. 
Although  the  cranial  presentations  are  much  the  most  common,  averag- 
ing 96  out  of  every  100  cases,  other  presentations  are  by  no  means  rare, 
the  next  most  frequent  being  either  that  of  the  breech,  in  which  the  long 
diameter  of  the  child  lies  in  the  long  diameter  of  the  uterine  cavity,  or 
some  variety  of  transverse  presentation,  in  which  the  long  diameter  of 
the  foetus  lies  obliquely  across  the  uterus,  and  no  longer  corresponds  to 
its  longitudinal  axis. 

Changes  of  Foetal  Position  during  Pregnancy. — It  was  long  believed 
that  the  head  presentation  was  only  assumed  toward  the  end  of  preg- 
nancy, when  it  was  supposed  to  be  produced  by  a  sudden  movement  on 
the  part  of  the  foetus,  known  as  the  culbute.  It  is  now  well  known  that, 
in  the  large  majority  of  cases,  the  head  is  lowest  during  all  the  latter  part 
of  pregnancy,  although  changes  in  position  are  more  common  than  is 
generally  believed  to  be  the  case,  and  presentation  of  parts  other  than 
tlie  head  is  much  more  frequent  in  premature  labor  than  in  deliver}'  at 
term.  In  evidence  of  the  last  statement,  Churchill  says  that  in  labor 
at  the  seventh  month  the  head  presents  only  83  times  out  of  100  when 
the  c;hild  is  living,  and  that  as  many  as  53  per  cent,  of  the  presentations 
an;  preternatural  when  the  child  is  stillborn.  The  frc(|uency  with 
wliich  the  fetus  changes  its  ])ositi()n  before  delivery  has  been  made  the 
subject  of  investigation  by  various  (jierman  obstetricians,  ;vnd  the  fact 
can  be  readily  ascertained  by  examination.  Valenta^  found  that  out 
of  nearly  1000  cases,  carefully  and  frequently  examined  by  him,  in 
57.6  ])er  c(!nt.  the  presentation  underwent  no  change  in  the  latter 
montlis  of  pn.'gnancy,  but  in   the  remaining  42.4  per  cent,  a  ciiange 

'  Sf'lecled  Obnl.  Worh,  n.  'M\?>.  ^  Man./.  Oelmrl.,  ISGG. 


124 


PREGNANCY. 


could  be  readily  detected.  These  alterations  were  found  to  be  most 
frequent  in  multiparse,  and  the  tendency  was  for  abnormal  presentations 
to  alter  into  normal  ones.  Thus  it  was  common  for  transverse  pres- 
entations to  alter  longitudinally,  and  but  rare  for  breech  presentations 
to  change  into  head.  The  ease  with  ^vhich  these  changes  are  effected  no 
doubt  depends,  in  a  considerable  degree,  on  the  laxity  of  the  uterine 
parietes  and  on  the  greater  quantity  of  amniotic  fluid,  by  both  of  Avliich 
the  free  mobility  of  the  foetus  is  favored. 

Detection  of  Foetal  Position  by  Abdominal  Palpation. — The  facility 
with  which  the  position  of  the  foetus  in  utero  can  be  ascertained  by 
abdominal  palpation  has  not  been  generally  appreciated  in  obstetric 
works,  and  yet  by  a  little  practice  it  is  easy  to  make  it  out.  Much 
information  of  importance  can  be  gained  in  this  way,  and  it  is  quite 
possible,  under  favorable  circumstances,  to  alter  abnormal  presentations 
before  labor  ha^  begun.     For  the  purpose  of  making  this  examination 

Fig.  67. 


Mode  of  Ascertaining  the  Position  of  the  Foetus  by  Palpation. 

the  patient  should  lie  at  the  edge  of  the  bed,  with  her  shoulders  slightly 
raised  and  the  abdomen  uncovered.  The  first  observation  to  make  is  to 
see  if  the  longitudinal  axis  of  the  uterine  tumor  corresponds  with  that 
of  the  mother's  abdomen ;  if  it  does,  the  presentation  must  be  either  a 
head  or  a  breech.  By  spreading  the  hands  over  the  uterus  (Fig.  67)  a 
greater  sense  of  resistance  can  be  felt,  in  most  cases,  on  one  side  than  on 
the  other,  corresponding  to  the  back  of  the  child.  By  striking  the  tips 
of  the  fingers  suddenly  inward  at  the  fundus,  the  hard  breech  can 
generally  be  made  out,  or  the  head  still  more  easily  if  the  breech  be 
down^^'ard.  When  the  uterine  walls  are  unusually  lax,  it  is  oflen 
possible  to  feel  the  limbs  of  the  child.  These  observations  can  be 
generally  corroborated  by  auscultation,  for  in  head  presentations  the 
foetal  heart  can  usually  be  heard  below  the  umbilicus,  and  in  breech 
cases  above  it.     Transverse  presentations  can  even  more  easily  be  made 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        125 

out  by  abdominal  palpation.  Here  the  long  axis  of  the  uterine  tumor 
does  not  correspond  with  the  long  axis  of  the  mother's  abdomen,  but 
lies  obliquely  across  it.  By  palpation  the  rounded  mass  of  the  head 
can  be  easily  felt  in  one  of  the  mother's  flanks,  and  the  breech  in  the 
other,  while  the  foetal  heart  is  heard  pulsating  nearer  to  the  side  at 
which  the  head  is  detected. 

Explanation  of  the  Position  of  the  Foetus  in  Utero. — The  reason  why 
the  head  presents  so  frequently  has  been  made  the  subject  of  much  dis- 
cussion. The  oldest  theory  was,  that  the  head  lay  over  the  os  uteri  as 
the  result  of  gravitation ;  and  the  influence  of  gravity,  although  con- 
tested by  many  obstetricians,  prominent  among  whom  were  Dubois  and 
Simpson,  has  been  insisted  upon,  as  the  chief  cause  by  others.  Dr.  Duncan 
being  one  of  the  most  strenuous  advocates  of  this  view.  The  objections 
urged  against  the  gravitation  theory  were  drawn  partly  from  the  result 
of  exj)eriments,  and  partly  from  the  frequency  with  which  abnormal 
presentations  occur  in  premature  labors,  when  the  action  of  gravity 
cannot  be  supposed  to  be  suspended.  The  experiments  made  by  Dubois 
went  to  show  that  when  the  foetus  was  suspended  in  water  gravitation 
caused  the  shoulders,  and  not  the  head,  to  fall  lowest.  He  therefore 
advanced  the  hypothesis  that  the  position  of  the  foetus  was  due  to 
instinctive  movements  which  it  made  to  adapt  itself  to  the  most  com- 
fortable position  in  which  it  could  lie.  It  need  only  be  remarked  that 
there  is  not  the  slightest  evidence  of  the  foetus  possessing  any  such 
power.  Simpson  proposed  a  theory  which  was  much  more  plausible. 
He  assumed  that  the  foetal  position  was  due  to  reflex  movements  pro- 
duced by  physical  irritations  to  which  the  cutaneous  surface  of  the  foetus 
is  subjected  from  changes  of  the  mother's  position,  uterine  contractions, 
and  the  like.  The  absence  of  these  movements  in  the  case  of  the  death 
of  the  foetus  would  readily  explain  the  frequency  of  mal-presentations 
under  such  circumstances.  The  obvious  objection  to  this  theory,  com- 
plete as  it  seems  to  be,  is  the  absence  of  any  proof  that  such  constant 
extensive  reflex  movements  really  do  occur  in  utero.  Dr.  Duncan  has 
very  conclusively  disposed  of  the  principal  objections  which  have  been 
raised  against  the  influence  of  gravitation,  and  when  an  obvious  ex- 
planation of  so  simple  a  kind  exists  it  seems  useless  to  seek  farther  for 
another.  He  has  shown  that  Dubois's  experiments  did  not  accurately 
represent  the  state  of  the  foetus  in  utero,  and  that  during  the  greater 
part  of  the  day,  when  the  woman  is  upright  or  lying  on  her  back,  the 
foetus  lies  obliquely  to  the  horizon  at  an  angle  of  about  30°.  The  child 
thus  lies,  in  the  former  case,  on  an  inclined  plane  formed  by  the  anterior 
uterine  wall  and  by  the  abdominal  parietes ;  in  the  latter,  by  the  pos- 
terior uterine  wall  and  the  vertebral  column.  Down  the  inclined  plane 
so  formed  the  force  of  gravity  causes  the  foetus  to  slide,  and  it  is  only 
when  the  woman  lies  on  her  side  that  the  foetus  is  placed  horizontally, 
and  is  not  subjected  in  the  same  degree  to  the  action  of  gravity  (Fig.  ()8). 
The  fre(|uency  of  mal-presentations  in  premature  labors  is  ex])laincd  l)y 
Dr.  Duncan  partly  by  the  fact  that  the  death  of  the  child  (which  so 
fre(jU(;ntly  precedes  such  cases)  alters  its  centre  of  gravity,  and  jiartly 
by  the  greater  mobility  of  the  child  and  the  greater  relative  amount  of 
lifjuor  amnii  (Fig.  00).    The  influence  of  gravitation  is  pr()l)ably  greatly 


126 


PREGNANCY. 


assisted  by  the  contractions  of  the  uterus  which  are  going  on  during  the 
greater  part  of  pregnancy.  The  influence  of  these  was  pointed  out  Ijy 
.Dr.  Tyler  Smith,  who  distinctly  showed  that  the  contractions  of  the 
uterus  preceding  delivery  exerted  a  moulding  or  adapting  influence  on 


Diagram  iUustrating  the  effect  of  Gravity  on  the  Foetus.    (After  Duncan.) 

a,  b,  is  parallel  to  the  axis  of  the  pregnant  uterus  and  pelvic  brim ;  c,  d,  e,  is  a  perpendicular  line :  e,  the 

centre  of  gravity  of  the  fcetus ;  d,  the  centre  of  flotation. 

the  foetus,. and  prevented  undue  alterations  of  its  position.  Dr.  Hicks 
proved^  that  these  uterine  contractions  are  of  constant  occurrence  from 
the  earliest  period  of  pregnancy,  and  there  can  be  little  doubt  that  they 
must  have  an  important  influence  on  the  body  contained  within  the 

Fig.  69. 


Illustrating  the  greater  Mobility  of  the  Foetus  and  the  larger  relative  amount  of  Liquor  Amnii 

in  Early  Pregnancy.    (After  Duncan.) 

((,  6.  Axis  of  pregnant  uterus.  b,  h.  A  horizontal  iine. 

uterus.  The  whole  subject  has  been  recently  considered  by  Pinard,^ 
who  shows  that  many  factors  are  in  action  to  produce  and  maintain  the 
usual  position  of  the  foetus  in  utero,  which  may  be  either  of  an  active 
or  a  passive  character — the  former  being  chiefly  the  active  movements 

^  Obat.  Trans.,  vol.  xiii.  p.  216.  ^  Annal.  cle  Gyn.,  May  and  July,  1878. 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        127 

of  the  foetus  and  the  contractions  of  the  uterus  and  the  abdominal 
muscles ;  the  latter,  the  form  of  the  uterus  and  the  foetus,  the  slippery 
surface  of  the  amnion,  pressure  of  the  amniotic  fluid,  etc.  When  any 
of  these  factors  are  at  fault,  mal-presentation  is  apt  to  occur, 

i^Wc^ious^j?7ig  i^^fws, — The  functions  of  the  foetus  are  in  the  main 
the  same,  with  differences  depending  on  the  situation  in  which  it  is  placed, 
as  those  of  the  separate  being.  It  breathes,  it  is  nourished,  it  forma 
secretions,  and  its  nervous  system  acts.  The  mode  in  which  some  of 
these  functions  are  carried  on  in  intra-uterine  life  requires  separate  con- 
sideration. 

Nutrition- — During  the  early  part  of  pregnancy,  and  before  the  forma- 
tion of  the  umbilical  vesicle  and  the  allantois,  it  is  certain  that  nutritive 
material  must  be  supplied  to  the  ovum  by  endosmosis  through  its  exter- 
nal envelope.  The  precise  source,  however,  from  which  this  is  obtained 
is  not  positively  known.  By  some  it  is  believed  to  be  derived  from  the 
granulations  of  the  discus  proligerus  which  surround  it  as  it  escapes 
from  the  Graafian  follicle,  and  subsequently  from  the  layer  of  albumin- 
ous matter  which  surrounds  the  ovum  before  it  reaches  the  uterus  ;  while 
others  think  it  probable  that  it  may  come  from  a  special  liquid  secreted 
by  the  interior  of  the  Fallopian  tube  as  the  ovum  passes  along  it.  As 
soon  as  the  ovum  has  reached  the  uterus  there  is  every  reason  to  believe 
that  the  umbilical  vesicle  is  the  chief  source  of  nourishment  to  the 
embryo,  through  the  channel  of  the  omphalo-mesenteric  vessels,  which 
convey  matters  absorbed  from  the  interior  of  the  vesicle  to  the  intestinal 
canal  of  the  foetus.  At  this  time  the  exterior  of  the  ovum  is  covered  by 
the  numerous  fine  villosities  of  the  primitive  chorion  which  are  imbedded 
in  the  mucous  membrane  of  the  uterus,  and  it  is  thought  that  they  may 
absorb  materials  from  the  maternal  system,  which  may  be  either  directly 
absorbed  by  the  embryo,  or  which  may  serve  the  purpose  of  replacing 
the  nutritive  matter  which  has  been  removed  from  the  umbilical  vesicle 
by  the  omphalo-mesenteric  vessels.  This  point  it  is,  of  course,  impossi- 
ble to  decide.  Joulin,  however,  thinks  that  these  villi  probably  have 
no  direct  influence  on  the  nourishment  of  the  foetus,  which  is  at  this 
time  solely  effected  by  the  umbilical  vesicle,  but  that  they  absorb  fluid 
from  the  maternal  system,  which  passes  through  the  amnion  and  forms 
the  liquor  amnii.  As  soon  as  the  allantois  is  developed,  vascular  com- 
munication between  the  foetus  and  the  maternal  structures  is  established, 
and  the  temporary  function  of  the  umbilical  vesicle  is  over :  that  struc- 
ture, therefore,  rapidly  atrophies  and  disappears,  and  the  nutrition  of  the 
foetus  is  now  solely  carried  on  by  means  of  the  chorion  villi,  lined  as 
they  now  are  by  the  vascular  endo-chorion,  and  chiefly  by  those  which 
go  to  form  the  substance  of  the  placenta. 

This  statement  is  op])Osed  to  the  views  of  many  physiologists,  who 
believe  that  a  certain  amount  of  nutritive  material  is  conveyed  to  the 
fijctus  througli  the  channel  of  the  licpior  amnii,  itself  derived  from  the 
matorna]  system,  whicli  is  supposed  either  to  Ik;  absoi'bed  througli  the 
cutaneous  surface  of  the;  fwtus  or  carried  to  tlie  intestinal  canal  by  deglu- 
tition. The  reasons  fi)r  assigning  to  the  licjuor  a  nutritive  function  are, 
however,  so  slight  that  it  is  difficult  to  believe  that  it  has  any  apprecia- 
l)lc  action  in  this  way.    They  are  based  on  some  cpiestionablc  observations, 


128  PREGNANCY. 

such  as  those  of  Weydlich,  who  kept  a  calf  alive  for  fifteen  days  by  feeding 
it  solely  on  liquor  amnii,  and  the  experiments  of  Burdaoh,  who  found  the 
cutaneous  lymphatics  engorged  in  a  foetus  removed  from  the  amniotic 
cavity,  while  those  of  the  intestine  were  empty.  The  deglutition  of  the 
liquor  amnii  for  the  purposes  of  nutrition  has  been  assumed  from  its 
occasional  detection  in  the  stomach  of  the  foetus,  the  presence  of  which 
may,  however,  be  readily  explained  by  spasmodic  efforts  at  res])iration 
which  the  foetus  undoubtedly  often  makes  before  birth,  especially  M'lien 
the  placental  circulation  is  in  any  way  interfered  with,  and  during  which 
a  certain  quantity  of  fluid  would  necessarily  be  swallowed.  The  quantity 
of  nutritive  material,  however,  in  the  liquor  amnii  is  so  small — not  more 
than  6  to  9  parts  of  albumen  in  1000 — that  it  is  impossible  to  conceive 
how  it  could  have  any  appreciable  influence  in  nutrition,  even  if  its 
absorption,  either  by  the  skin  or  stomach,  ^vere  susceptible  of  proof 

That  the  nutrition  of  the  foetus  is  effected  through  the  placenta  is 
proved  by  the  common  observation  that  whenever  the  placental  circula- 
tion is  arrested,  as  by  disease  of  its  structure,  the  foetus  atrophies  and 
dies.  The  precise  mode,  however,  in  which  nutritive  materials  are 
absorbed  from  the  maternal  blood  is  still  a  matter  of  doubt,  and  must 
remain  so  until  the  mooted  points  as  to  the  minute  anatomy  of  the  pla- 
centa are  settled.  The  various  theories  entertained  on  this  subject  by 
the  upholders  of  the  Hunterian  doctrine  of  placental  anatomy,  and  by 
those  who  deny  the  existence  of  a  sinus  system,  have  already  been  referred 
to  in  the  chapter  on  the  Anatomy  of  the  Placenta,  to  which  the  reader 
is  referred  (pp.  111-115). 

Respiraiion. — One  of  the  chief  functions  of  the  placenta,  besides  that 
of  nutrition,  is  the  supply  of  oxygenated  blood  to  the  foetus.  That  this 
is  essential  to  the  vitality  of  the  foetus,  and  that  the  placenta  is  the  site 
of  oxygenation,  is  shown  by  the  fact  that  whenever  the  placenta  is  sepa- 
rated, or  the  access  of  foetal  blood  to  it  arrested  by  compression  of  the 
cord,  instinctive  attempts  at  inspiration  are  made,  and  if  aerial  respira- 
tion cannot  be  performed  the  foetus  is  expelled  asphyxiated.  Like  the 
other  functions  of  the  foetus  during  intra-uterine  life,  that  of  respiration 
has  been  made  the  subject  of  numerous  more  or  less  ingenious  hypotheses. 
Thus,  many  have  believed  that  the  foetus  absorbed  gaseous  material  from 
the  liquor  amnii,  which  served  the  purpose  of  oxygenating  its  blood,  St. 
Hilaire  thinking  that  this  was  effected  by  minute  openings  in  its  skin, 
Beclard  and  others  through  the  bronchi,  to  which  they  believed  the 
liquor  amnii  gained  access.  Independently  of  the  entire  want  of  evi- 
dence of  the  absorption  of  gaseous  materials  by  these  channels,  the  theory- 
is  disproved  by  the  fact  that  the  liquor  amnii  contains  no  air  A^liich  is 
capable  of  respiration.  Serres  attributed  a  similar  function  to  some  of 
the  cliorion  villi,  which  he  believed  penetrated  the  utricular  glands  of 
the  decidua  reflexa  and  absorbed  gas  from  the  hydroperione,  or  fluid 
situated  between  it  and  the  decidua  vera,  and  in  this  manner  he  thought 
the  foetal  blood  was  oxygenated  until  the  fifth  month  of  intra-uterine 
life,  when  the  placenta  was  fully  formed. 

This  hypothesis,  however,  rests  on  no  accurate  foundation,  for  it  is 
certain  that  the  chorion  villi  do  not  penetrate  the  utricular  glands  in  tlie 
manner  assumed ;  or,  even  if  they  did,  the  mode  in  which  the  oxygen 


THE  ANATOMY  AND  PHYSIOLOGY  OF  THE  FCETUS.        129 

thus  absorbed  by  the  chorion  villi  reaches  the  foetus,  which  is  separated 
from  them  by  the  amnion  and  its  contents,  would  still  remain  unexplained. 

The  mode  in  which  the  oxygenation  of  the  foetal  blood  is  effected 
before  the  formation  of  the  placenta  remains,  therefore,  as  yet  unknown. 
After  the  development  of  that  organ,  however,  it  is  less  difficult  to  under- 
stand, for  the  foetal  blood  is  everywhere  brought  into  such  close  contact 
with  the  maternal,  in  the  numerous  minute  ramifications  of  the  umbili- 
cal vessels,  that  the  interchange  of  gases  can  readily  be  effected.  The 
activity  of  respiration  is  doubtless  much  less  than  in  extra-uterine  life, 
for  the  waste  of  tissue  in  the  foetus  is  necessarily  comparatively  small, 
from  the  fact  of  its  being  suspended  in  a  fluid  medium  of  its  own  tem- 
perature, and  from  the  absence  of  the  processes  of  digestion  and  of 
respiratory  movements.  The  quantity  of  carbonic  acid  formed  would, 
therefore,  be  much  less  than  after  birth,  and  there  would  be  a  corre- 
spondingly small  call  for  oxygenation  of  venous  circulation. 

Circulation. — The  functions  of  the  lungs  being  in  abeyance,  it  is  neces- 
sary that  all  the  foetal  blood  should  be  carried  to  the  placenta  to  receive 
oxygen  and  nutritive  materials.  To  understand  the  mode  in  which  this 
is  effected  we  must  bear  in  mind  certain  peculiarities  in  the  circulatory 
system  which  disappear  after  birth. 

1.  The  two  sides  of  the  foetal  heart  are  not  sejjarate,  as  in  the  adult. 
The  rio-ht  ventricle  in  the  adult  sends  all  the  venous  blood  to  the  lungs 
through  the  pulmonary  arteries,  to  be  aerated  by  contact  with  the  atmo- 
sphere. In  the  foetus,  however,  only  sufficient  blood  is  passed  through 
the  pulmonary  arteries  to  ensure  their  being  pervious  and  ready  to  carry 
blood  to  the  lungs  immediately  after  birth. 

An  aperture  of  communication,  the  foramen  ovale^  exists  between  the 
two  auricles,  which  is  arranged  so  as  to  permit  the  blood  reaching  the 
right  auricle  to  pass  freely  into  the  left,  but  not  vice  versa.  By  this 
means  a  large  portion  of  the  blood  reaching  the  heart  through  the  vense 
cavse,  instead  of  passing,  as  in  the  adult,  into  the  right  ventricle,  is 
directed  into  the  left  auricle. 

2.  Even  with  this  arrangement,  however,  a  larger  portion  of  blood 
would  pass  into  the  pulmonary  arteries  than  is  required  for  transmission  to 
the  lungs,  and  a  further  provision  is  made  to  prevent 

its  going  to  them  by  means  of  a  foetal  vessel,  the  ^i^'-  "^j_ 

ductus  arteriosus  (Fig.  70),  which  arises  from  the      ■^ 
point  of  bifurcation  of  the  pulmonary  arteries  and   ^^^^ 
opens  into  the  arch  of  the  aorta.     In  consequence 
of  tills  arrangement  only  a  very  small  portion  of 
tlio  blood  reaches  the  lungs  at  all. 

3.  The  foetal  hypogastric  arteries  are  continued 
into  large  arterial  trunks,  which,"  passing  into  the 
cord,  form  the  umhilical  arteries,  and  carry  the  ira-  Diagram  of  Fostai  Heart. 
pure  foetal  blood  into  the  placieuta.  (After  uaiton.) 

4.  The  purified  blood  is  collected  into  the  single     2!  Putaonaw  artery. 
umMHcalvein,  through   which   it  is  carried  to  the     4]  Lcu!rmtnCur^ 
under  surface  of  the  liver^  from  whi(-h   point  it  Js 
cQiiiliictedr-by  means  of  another  special  foetal  vessel,  the  ductus  venosus, 
i nto  the  ascending  vena  cava  and  the  right  auricle. 

9 


130  PREGNANCY. 

Course  of  thsJFoetal  Oirculglion. — In  order  to  understand  the  course 
of  tlie  foetal  blood,  it  may  be  most  conveniently  traced  from  the  point 
where  it  reaches  the  under  surface  of  the  liver  through  the  umbilical 
vein.  Part  of  it  is  distributed  to  the  liver  itself,  but  the  greater  quan- 
tity is  carried  directly  into  the  inferior  vena  cava  through  the  ductus 
venosus.  The  inferior  vena  cava  also  receives  the  blood  from  the  foetal 
veins  of  the  lower  extremities  and  that  portion  of  the  blood  of  the  um- 
bilical vein  which  has  passed  through  the  liver.  This  mixed  blood  is 
carried  up  to  the  right  auricle,  from  which  by  far  the  greater  part  of  it 
is  immediately  directed  into  the  left  auricle  through  the  foramen  ovale. 
From  thence  it  passes  into  the  left  ventricle,  which  sends  the  greater 
part  of  it  into  the  head  and  upper  extremities  through  the  aorta,  a  com- 
paratively small  quantity  being  transmitted  to  the  inferior  extremities. 
The  blood  which  is  thus  sent  to  the  upper  part  of  the  body  is  collected 
into  the  vena  cava  superior,  by  which  it  is  thrown  into  the  right  auricle. 
Here  the  mass  of  it  is  probably  directed  into  the  right  ventricle,  which 
expels  it  into  the  pulmonary  arteries,  and  from  thence,  through  the  duc- 
tus arteriosus,  into  the  descending  aorta.  By  this  arrangement  it  will 
be  seen  that  the  descending  aorta  conveys  to  the  low^er  part  of  the  body 
the  comparatively  impure  blood  which  has  already  circulated  through 
the  head,  neck  and  upper  extremities.  From-  the  descending  aorta  a 
small  quantity  of  blood  is  conveyed  to  the  lower  extremities,  the  greater 
part  of  it  being  carried  for  purification  to  the  placenta  through  the  um- 
bilical arteries. 

Establishment  of  IndepmdmiAJireuJnMon. — As  soon  as  the  child  is 
born  It  generally  cries  loudly  aiid  inflates  its  lungs,  and,  in  consequence, 
the  pulmonary  arteries  are  dilated,  and  the  greater  portion  of  the  blood 
of  the  right  ventricle  is  at  once  sent  to  the  lungs,  from  whence,  after 
being  arterialized,  it  is  returned  to  the  left  auricle  through  the  pulmonary 
veins.  The  left  auricle,  therefore,  receives  more  blood  than  before,  the 
right  less,  and,  the  placental  circulation  being  arrested,  no  more  passes 
through  the  umbilical  vein.  In  consequence  of  this,  the  pressure  of  the 
blood  in  the  two  auricles  is  equalized ;  the  mass  of  the  blood  in  the  right 
auricle  no  longer  passes  into  the  left  (the  valve  of  the  foramen  ovale 
being  closed  by  the  equal  pressure  on  both  sides),  but  directly  into  the 
right  ventricle,  and  from  thence  into  the  pulmonary  arteries,  and  the 
ductus  arteriosus  soon  collapses  and  becomes  impervious.  The  mass  of 
blood  in  the  descending  aorta  no  longer  finds  its  way  into  the  hypogas- 
tric arteries,  but  passes  into  the  lower  extremities,  and  the  adult  circula- 
tion is  established. 

Chanqesin  Fwtal  Circulation  after  Birth. — The  changes  which  take 
place7ntlie~tenipnrary  vascular  arrangements  of  the  foetus  prior  to  their 
complete  disappearance  are  of  some  practical  interest.  The  ductus  arte- 
riosus, as  has  been  said,  collapses,  chiefly  because  the  mass  of  blood  is 
drawn  to  the  lungs,  and  partly,  perhaps,  by  its  own  inherent  contract- 
ility. Its  walls  are  found  to  be  thickened,  and  its  canal  closes,  first  in 
the  centre,  and  subsequently  at  its  extremities,  its  aortic  end  remaining 
longer  pervious  on  account  of  the  greater  pressure  of  blood  from  the 
left" side  of  the  heart  (Fig.  71).  Practical  closure  occurs  within  a  few 
days  after  birth,  although  Flourens  states  that  it  is  not  completely  oblit- 


THE  ANAT03IY  AND  PHYSIOLOGY  OF  THE  FCETUS.        131 

erated  until  eighteen  months  or  two  years  have  elapsed/  According  to 
Schroeder,  its  walls  unite  without  the  formation  of  any  thrombus.  The 
foramen  ovale  is  soon  closed  by  its  valve,  which  contracts  adhesion  with 
the  edges  of  the  aperture,  so  as  effectually  to 
occlude  it.    Sometimes,  however,  a  small  canal  I  ^^^-  '^^• 

of  communication  between  the  two  auricles 
may  remain  pervious  for  many  months,  or 
even  a  year  and  more,  without,  however,  any 
admixture  of  blood  occurring.  A  perma- 
nently patulous  condition  of  this  aperture, 
however,  sometimes  exists,  giving  rise  to  the 
disease  known  as  cyanosis. 

The  umbilical  arteries  and  veins  and  the 
ductus  venosus  soon  also  become  impermeable, 
in  consequence  of  concentric  hypertrophy  of 
their  tissue  and  collapse  of  their  walls.     The  J     Diagram  orn^rt  of  infant. 
closure  of  the  former  is  aided  by  the  forma-  (After  Daiton.) 

,  •  n  1        •        xi         •     J       •  A  T  1-  Aorta.        2.  Pulmonary  artery. 

tion  ot  coagula  m  the  interior.     According     3, 3.  Pulmonary  branches. 

to  Eobin,  a  longer  time  than  is  usually  sup-    *•  i>«;^us^  arteriosus  becoming  obiit- 

posed  elapses  before  they  become  completely 

closed,  the  vein  remaining  pervious  until  the  twentieth  or  thirtieth  day 

after  delivery,  the  arteries  for  a  month  or  six  weeks.      He  has  also 

described^  a  remarkable  contraction   of  the  umbilical  vessels  within 

their  sheaths  at  the  point  where  they  leave  the  abdominal  walls,  which 

takes  place  within  three  or  four  days  after  birth,  and  seems  to  prevent 

hemorrhage  taking  place  when  the  cord  is  detached. 

Function  of  the  Liver. — The  liver,  from  its  proportionately  large  size, 
apparently  plays  an  important  part  in  the  foetal  economy.  It  is  not 
until  about  the  fifth  month  of  utero-gestation  that  it  assumes  its  charac- 
teristic structure,  and  forms  bile,  previous  to  that  time  its  texture  being 
soft  and  undeveloped.  According  to  Claude  Bernard,  after  this  period 
one  of  its  most  important  offices  is  the  formation  of  sugar,  which  is 
found  in  much  larger  amount  in  the  foetus  than  after  birth.  Sugar  is, 
however,  found  in  the  foetal  structures  long  before  the  devel(5pment  of 
the  liver,  especially  in  the  mucous  and  cutaneous  tissues,  and  it  seems 
probable  that  these,  as  well  as  the  placenta  itself,  then  fulfil  the  glyco- 
genic function  afterward  chiefly  performed  by  the  liver.  The  bile  is 
secreted  after  the  fifth  month  of  pregnancy,  and  passes  into  the  intestinal 
canal,  and  is  subsequently  collected  in  the  gall-bladder.  By  some  phys- 
iologists it  has  been  supposed  that  the  liver  during  intra-uterine  life  was 
the  chief  seat  of  depuration  of  the  carbonic  acid  contained  in  the  venous 
l^lood  of  the  foetus.  It  i.s,  however,  more  generally  believed  that  this 
is  accomj)lished  solely  in  the  placenta. 

The  Meconium. — The  bile,  mixed  with  the  mucous  secretion  of  the 
intestinal  tract,  forms  the  meconium,  which  is  contained  in  the  intestines 
of  tlie  fijetus,  and  which  collects  in  them  during  the  whole  period  of 
intra-uterine  life.  It  is  a  thick,  tenacious,  greenish  substance,  which  is 
voided  soon  after  birth  in  considerable  <]uantity. 

The  Urine. — Urine  is  certainly  formed  during  intra-uterine  life,  as  is 
'  Acad,  des  Sciences,  18.J4.  2  jf^if^^^  isqq. 


132  PREGNANCY. 

proved  bv  the  fact,  familiar  to  all  accoucheurs,  that  the  bladder  is  con- 
stantly emptied  instantly  after  birth.  It  has  generally  been  supposed 
that  the  foetus  voids  its  urine  into  the  cavity  of  the  amnion,  and  the 
existence  of  traces  of  urea  in  the  li(}uor  amnii,  as  well  as  some  cases  of 
imperforate  urethra,  in  which  the  bladder- was  found  to  be  enormously 
distended,  and  some  cases  of  congenital  hydronephrosis  associated  with 
impervious  ureters,  have  been  supposed  to  corroborate  this  assumption. 
The  question  has  been  very  fully  studied  by  Joulin,  who  has  collected 
together  a  large  number  of  instances  in  which  there  was  im})erforale 
urethra  without  any  undue  distension  of  the  bladder.  He  holds,  also, 
that  the  amount  of  urea  found  in  the  liquor  amnii  is  far  too  minute  to 
justify  the  conclusion  that  the  urine  of  the  foetus  Avas  ha])itually  })assed 
into  it,  although  a  small  quantity  may,  he  thinks,  escape  into  it  from 
time  to  time ;  and  he  therefore  believes  that  the  urine  of  the  foetus  is 
only  secreted  regularly  and  abundantly  after  birth,  and  that  during  intra- 
uterine life  its  retention  is  not  likely  to  give  rise  to  any  functional  dis- 
turbance.^ 

Function  of  the  Nervous  System. — There  is  no  doubt  that  the  nervous 
system  acts  to  a  considerable  extent  during  intra-uterine  life,  and  some 
authors  have  even  supposed  that  the  foetus  was  endowed  with  the  power 
of  making  instinctive  or  voluntary  movements  for  the  purpose  of  adapt- 
ing itself  to  the  form  of  the  uterine  cavity.  Most  probably,  however, 
the  movements  the  foetus  performs  are  purely  reflex.  That  it  responds 
to  a  stimulus  applied  to  the  cutaneous  nerves  is  proved  by  the  experi- 
ments of  Tyler  Smith,  who  laid  bare  the  amnion  in  pregnant  rabbits, 
and  found  that  the  foetus  moved  its  limbs  when  these  were  irritated 
through  it.  Pressure  on  the  mother's  abdomen,  cold  applications,  and 
similar  stimuli  will  also  produce  energetic  foetal  movements.  The  gray 
matter  of  the  brain  in  the  new-born  child  is,  however,  quite  rudiment- 
ary in  its  structure,  and  there  is  no  evidence  of  intelligent  action  of  the 
nervous  system  until  some  time  after  birth,  and,  a  fortiori,  during  preg- 
nancy. 


CHAPTER   III, 
PEEGNANCY. 


As  soon  as  conception  has  taken  place  a  series  of  remarkable  changes 
commence  in  the  uterus,  which  progress  until  the  termination  of  preg- 
nancy, and  are  well  worthy  of  careful  study.  They  produce  those  mar- 
vellous modifications  which  effect  the  transformation  of  the  small 
undeveloped  uterus  of  the  non-pregnant  state  into  the  large  and 
fully-developed  uterus  of  pregnancy,  and  have  no  parallel  in  the  whole 
animal  economy. 

A  knowledge  of  them  is  essential  for  the  proper  comprehension  of  the 

^  Acad,  des  Sciences,  p.  308. 


PREGNANCY. 


133 


phenomena  of  labor  and  for  the  diagnosis  of  pregnancy  which  the  prac- 
titioner is  so  frequently  called  upon  to  make.  Excluding  the  varieties  of 
abnormal  pregnancy,  which  will  be  noticed  in  another  place,  we  shall 
here  limit  ourselves  to  the  consideration  of  the  modifications  of  the 
maternal  organism  which  result  from  simple  and  natural  gestation. 

Changes  in  the  Uterus. — The  unimpregnated  uterus  measures  2^  inches 
in  length  and  weighs  about  1  oz.,  while  at  the  full  term  of  pregnancy  it 
has  so  immensely  grown  as  to  weigh  24  oz.  and  measure  12  inches.  The 
growth  commences  as  soon  as  the  ovum  reaches  the  uterus,  and  continues 

Fig.  72. 


Relations  of  the  Pregnant  Uterus  at  Sixth  Month  to  the  Surrounding  Parts.    (After  Martin. 


uninterruptedly  until  delivery.  In  the  early  months  the  uterus  is  con- 
tained entirely  in  the  cavity  of  the  pelvis,'  and  the  increase  of  size  is 
only  apparent  on  vaginal  examination,  and  that  with  difficulty.  Before 
the  third  month  the  enlargement  is  chiefly  in  the  lateral  direction,  so 
that  the  whole  body  of  the  uterus  assumes  more  of  a  spherical  slia]3e 
tlian  in  the  non-pregnant  state.  If  an  o]i])oi-tunity  of  examining  the 
gravid  liter m  pod-mo rtrm  sliould  occur  at  this  time,"  it  will  be  found  to 
liave  the  form  of  a  sphere  flattened  somewhat  j)osterior]y  and  bulging 
anteriorly. 

Aft(!r  the  ascent  of  the  organ  into  the  abdomen  it  develops  more  in  i 
the  vertical  direction,  so  that  at  terra  it  has  the  form  of  an  ovoid,  with 


134 


PREGNANCY. 


Fig.  73. 


its  large  extremity  above  and  its  narrow  end  at  the  cervix  uteri,  and  its 
longitudinal  axis  corresponds  to  the  long  diameter  of  the  mother's  abdo- 
men, provided  the  presentation  be  either  of  the  head  or  the  breech.  The 
anterior  surface  is  now  even  more  distinctly  projecting  than  before — a 
fact  which  is  explained  by  the  proximity  of  the  posterior  surface  to  the 
rigid  spinal  column  behind,  while  the  anterior  is  in  relation  \di\\  the  lax 
abdominal  parietes,  which  yield  readily  to  pressure,  and  so  allow  of  the 
more  marked  prominence  of  the  anterior  uterine  M-all. 

Change  in  Situation. — Before  the  gravid  uterus  has  risen  out  of  the 
pelvis  no  appreciable  increase  in  the  size  of  the  abdomen  is  perceptible. 
On  the  contrary,  it  is  an  old  observation  that  at  this  early  stage  of  preg- 
nancy the  abdomen  is  flatter  than  usual,  on  account  of  the  partial  de- 
scent of  the  uterus  in  the  pelvic  cavity  as  a  result  of  its  increased  weight. 
As  the  growth  of  the  organ  advances  it  soon  becomes  too  large  to  be 
contained  any  longer  within  the  pelvis,  and  about  the  middle  of  the  third 
or  the  beginning  of  the  fourth  month  the  fundus  rises  above  the  pelvic 
brim — not  suddenly,  as  is   often  erroneously  thought,  but  slowly  and 

gradually — when   it   may  be  felt   as   a 
smooth  rounded  swelling. 

Size  of  Uterine  Tumor  at  Various 
Periods  of  Pregnancy. — It  is  about  this 
time  that  the  movements  of  the  foetus 
first  become  appreciable  to  the  mother, 
Avhen  "  quiekening  "  is  said  to  have  taken 
place.  Toward  the  end  of  the  fourth 
month  the  uterus  reaches  to  about  three 
fingers^  breadth  above  the  symphysis 
pubis.  About  the  fifth  month  it  occu- 
pies the  hypogastric  region,  to  which  it 
imparts  a  marked  projection,  and  the 
alteration  in  the  figure  is  now  distinctly 
perceptible  to  visual  examination.  About 
the  sixth  month  it  is  on  a  Jevel  witli^or 
a  little  above,  the  umbilicus.  About  the 
seventh  month  it  is  about  two  inches 
above  the  umbilicits,  which  is  now  j3i*o- 
jecting  and  prominent,  instead  of  de- 
pressed, as  in  the  non-pregnant  state. 
During  the  eighth  and  ninth  months  it 
continues  to  increase  until  the  summit  of  tlie  fundus  is  inuiicdiately 
below  the  ensiform  cartilage  (Fig.  73).  A  kn(jwledge  of  tlie  size  of  the 
uterine  tumor  at  various  periods  of  pregnancy,  as  thus  indicated,  is  of 
considerable  practical  importance,  as  forming  the  only  guide  by  which 
we  can  estimate  the  probable  period  of  delivery  in  certain  cases  in  which 
the  usual  data  for  calculation  are  absent ;  as,  for  example,  when  the 
patient  has  conceived  during  lactation. 

The  Uterus  Sinks  before  Belivej-y — For  about  a  week  or  more  before 
labor  the  uterus  generally  sinks  somewhat  into  the  pelvic  cavity,  in  con- 
sequence of  the  relaxation  of  the  soft  parts  which  precedes  delivery,  and 
the  patient  now  feels  herself  smaller  and  lighter  than  before.     This 


Size  of  Uterus  at  Various  Periods  of 
Pregnancy. 


PREGNANCY.  135 

change  is  familiar  to  all  childbearing  women,  to  whom  it  is  known  as 
"the  lightening  before  labor." 

The  Direction  of  the  Uterus. — While  the  uterus  remains  in  the  pelvis 
its  longitudinal  axis  varies  in  direction,  much  in  the  same  way  as  that 
of  the  non-pregnant  uterus,  sometimes  being  more  or  less  vertical,  at 
others  in  a  state  of  anteversion  or  partial  retroversion.  These  variations 
are  probably  dependent  on  the  distension  or  emptiness  of  the  bladder,  as 
its  state  must  necessarily  affect  the  position  of  the  movable  organ  poised 
behind  it.  After  the  uterus  has  risen  into  the  abdomen  its  tendency  is 
to  project  forward  against  the  abdominal  wall,  which  forms  its  chief 
support  in  front.  In  the  erect  position  the  long  axis  of  the  uterine 
tumor  corresponds  with  the  axis  of  the  pelvic  brim,  forming  an  angle 
of  about  30°  with  the  horizon.  In  the  semi-recumbent  position,  on  the 
other  hand,  as  Duncan*  has  pointed  out,  its  direction  becomes  much 
more  nearly  vertical.  In  women  who  have  borne  many  children  the 
abdominal  parietes  no  longer  afford  an  efficient  support,  and  the  uterus 
is  displaced  anteriorly,  the  fundus  in  extreme  cases  even  hanging 
downward. 

Lateral  Obliquity  of  the  Uterus. — In  addition  to  this  anterior  obliq- 
uity, on  account  of  the  projection  of  the  spinal  column,  the  uterus  is 
very  generally  also  displaced  laterally,  and  sometimes  to  a  very  marked 
degree,  so  that  it  may  be  felt  entirely  in  one  flank,  instead  of  in  the 
centre  of  the  abdomen.  In  a  large  proportion  of  cases  this  lateral  devi- 
ation is  to  the  right  side,  and  many  hypotheses  have  been  brought  for- 
ward to  explain  this  fact,  none  of  them  being  satisfactory.  Thus,  it  has 
been  supposed  to  depend  on  the  greater  frequency  with  which  women 
lie  on  their  right  side  during  sleep,  on  the  greater  use  of  the  right  leg 
during  walking,  on  the  supposed  comparative  shortness  of  the  right 
round  ligament,  which  drags  the  tumor  to  that  side,  or  on  the  frequent 
distension  of  the  rectum  on  the  left  side,  which  prevents  the  uterus 
being  displaced  in  that  direction.  Of  these  the  last  is  the  cause  which 
seems  most  constantly  in  operation  and  most  likely  to  produce  the 
effect. 

Changes  in  the  Direction  of  the  Cervix. — The  cervix  must  obviously 
adapt  itself  to  the  situation  of  the  body  of  the  uterus.  We  find,  there- 
fore, that  in  the  early  months,  when  the  uterus  lies  low  in  the  pelvis,  it 
is  more  readily  within  reach.  After  the  ascent  of  the  uterus  it  is  drawn 
up,  and  frequently  so  much  so  as  to  be  reached  with  difficulty.  When 
the  uterus  is  much  ante  verted,  as  is  so  often  the  case,  the  os  is  displaced 
ba(jkward,  so  that  it  cannot  be  felt  at  all  by  the  examining  finger. 

Relation  of  the  Uterus  to  the  Surroitnding  Parts. — ToM'ard  the  end  of 
pregnancy  the  greater  part  of  the  anterior  surface  of  the  uterus  is  in 
contact  with  the  abdominal  wall,  its  lower  portion  resting  on  the  poste- 
rior surface  of  the  sym])hysis  pubis.  The  posterior  surflice  rests  on  the 
spinal  column,  while  the  small  intestines  are  pushed  to  either  side,  the 
large  intestines  surrounding  the  uterus  like  an  arch. 

Changes  in  the  Uterine  Parietes. — The  great  distension  of  the  uterus 
during    pregnancy  was    formerly  supposed  to   be    mainly  due   to  the 
mechanical  pressure  of  tlie  enlarging  ovum  within  it.     If  this  were  so, 
'  Eesearclien  in  ObnlelricH,  p.  10. 


136 


PREGNANCY. 


then  the  uterine  walls  would  be  necessarily  much  thinner  than  in  the 
non-pregnant  state.  This  is  well  known  not  to  be  the  case,  and  the 
immense  increase  in  the  size  of  the  uterine  cavity  is  to  be  explained 
by  the  hypertrophy  of  its  walls.  At  the  full  period  of  pregnancy  the 
thickness  of  the  uterine  parietes  is  generally  about  the  same  as  that  of 
the  non-pregnant  uterus,  rather  more  at  the  placental  site,  and  less  in 
the  neighborhood  of  the  cervix.  Their  thickness,  however,  varies  in 
different  places,  and  in  some  women  they  are  so  thin  as  to  admit  of  the 
I  foetal  limbs  being  very  readily  made  out  by  palpation.  Their  density 
is,  however,  always  much  diminished,  and  instead  of  being  hard  and 
inelastic  they  become  soft  and  yielding  to  pressure.  This  change  coin- 
cides with  the  commencement  of  pregnancy,  of  which  it  forms,  as  recog- 
nizable in  the  cervix,  one  of  the  earliest  diagnostic  marks.  At  a  more 
advanced  period  it  is  of  value  as  admitting  a  certain  amount  of  yielding 
of  the  uterine  walls  to  movements  of  the  foetus,  thus  lessening  the  chance 
of  their  being  injured. 

Changes  in  the  Cervix  during  Pregnancy. — Very  erroneous  views 
have  long  been  taught,  in  most  of  our  standard  works  on  midwifery,  as 
to  the  changes  which  occur  in  the  cervix  uteri  during  pregnancy.  It  is 
generally  stated  that  as  pregnancy  advances  the  cervical  cavity  is  greatly 
diminished  in  length,  in  consequence  of  its  being  gradually  drawn  up  so 
as  to  form  part  of  the  general  cavity  of  the  uterus,  so  that  in  the  latter 


Fig.  74. 


Fig.  75. 


Fig.  76. 


Fig.  77. 


Supposed  Shortening  of  the  Cervix  at  the  Third,  Sixth,  Eighth,  and  Ninth  Months  of  Pregnancy, 
as  figured  in  Obstetric  Works. 

months  it  no  longer  exi.sts.  In  almost  all  midwifery  works  accurate 
diagrams  are  given  of  this  progressive  shortening  of  the  cervix  (Figs. 
74  to  77).  The  cervix  is  generally  described  as  having  lost  one-half 
of  its  length  at  the  sixth  month,  two-thirds  at  the  seventh,  and  to  be 
entirely  obliterated  in  the  eighth  and  nintli.  The  correctness  of  these 
views  was  first  called  in  question  in  recent  times  by  Stoltz  in  1826,  but 
Dr.  Duncan,^  in  an  elaborate  historical  paper  on  the  subject,  has  shown 

^  Researches  in  Obstetrics. 


PREGNANCY. 


137 


that  Stoltz  was  anticipated  by  Weitbrech  in  1750,  and  to  a  less  degree 
by  Roederer  and  other  writers.  This  opinion  is  now  pretty  generally 
admitted  to  be  correct,  and  is  upheld  by  Cazeaux,  Arthur  Farre, 
Duncan,  and  most  modern  obstetricians.  Indeed,  various  post-mortem 
examinations  in  advanced  pregnancy  have  shown  that  the  cavity  of  the 
cervix  remains  in  reality  of  its  normal  length  of  one  inch,  and  it  can 
often  be  measured  during  life  by  the  examining  finger  on  account  of  its 
patulous  state  (Fig.  78).     During  the  fortnight  immediately  preceding 

Fig.  78. 


Cervix  from  a  Woman  dying  in  the  Eighth  Montli  of  Pregnancy.    (After  Duncan.) 

delivery,  however,  a  real  shortening  or  obliteration  of  the  cervical 
cavity  takes  place ;  but  this,  as  Duncan  has  pointed  out,  seems  to  be 
due  to  the  incipient  uterine  contractions  which  prepare  the  cervix  for 
labor. 

An  Apparent  Shortening  is  ahcays  Present. — There  is  no  doubt  an 
apparent  shortening  of  the  cervix  always  to  be  detected  during  preg- 
nancy, but  this  is  a  fallacious  and  deceptive  feeling,  due  to  the  softness 
of  the  tissue  of  the  cervix,  which  is  exceedingly  characteristic  of  preg- 
nancy, and  which  to  an  experienced  finger  affords  one  of  its  best  diag- 
no.stif;  marks. 

Hofteniwj  of  the  Cervix. — In  the  non-pregnant  state  the  tissue  of  the 
cervix  is  hard,  firm,  and  inelastic.  When  conception  occurs,  softening 
begins  at  the  external  os,  and  proceeds  gradually  and  slowly  upward 
until  it  involves  the  whole  of  the  cervix.  By  the  end  of  the  fourth 
month  b(>tli  Wyvr.  of  the  os  are  thic^k,  softened,  and  vel\;^y  to  the  tjoiK'h, 
giving  a  .scn.-^ation  likened  by  C.^azcaux  to  tliat  j)r(»du('(!d  by  ])r('ssing  on 
a  tabic  through  a  thick,  soft  cover.  By  the  si.xth  month  at  least  one- 
half  of  the  cervix  is  thus  altered,  and  by  the  eighth  the  whole  of  it,  and 


138  PREGNANCY. 

so  much  so  that  at  this  time  those  unaccustomed  to  vaginal  examination 
experience  some  difficulty  in  distinguishing  it  from  the  vaginal  walls. 
It  is  this  softening,  then,  which  gives  rise  to  the  apparent  shortening  of 
the  cervix  so  generally  described,  and  it  is  an  invaluable  concomitant 
of  pregnancy,  except  in  some  rare  cases  in  ^^'hich  there  has  been  antece- 
dent morbid  induration  and  hypertrophic  elongation  of  the  cervix.  If, 
therefore,  on  examining  a  woman  supposed  to  be  advanced  in  pregnancy, 
we  find  the  cervix  to  be  hard  and  projecting  into  the  vaginal  canal,  we 
may  safely  conclude  that  pregnancy  does  not  exist.  The  existence  of 
softening,  however,  it  must  be  remembered,  will  not  itself  justify  an 
opposite  conclusion,  as  it  may  be  produced,  to  a  very  considerable 
extent,  by  various  pathological  conditions  of  the  uterus. 

The  Os  Uteri  is  generally  Patulous. — At  the  same  time  that  the  tis- 
sue of  the  cervix  is  softened  its  cavity  is  widened  and  the  external  os 
becomes  patulous.  This  change  varies  considerably  in  primiparas  and 
multiparse.  In  the  former  the  external  os  often  remains  closed  until  the 
end  of  pregnancy,  but  even  in  them  it  generally  becomes  more  or  less 
patulous  after  the  seventh  month,  and  admits  the  tip  of  the  examining 
finger.  In  women  who  have  borne  children  this  change  is  much  more 
marked.  The  lips  of  the  external  os  are  in  them  generally  fissured  and 
irregular,  from  slight  lacerations  of  its  tissue  in  former  labors.  It  is  also 
sufficiently  open  to  admit  the  tip  of  the  finger,  so  that  in  the  latter 
months  of  pregnancy  it  is  often  quite  possible  to  touch  the  membranes, 
and  through  them  to  feel  the  presenting  part  of  the  child. 

Changes  in  the  Texture  of  the  Uterine  Tissues:  The  Peritoneal  Coat. 
— The  remarkable  increase  in  size  of  the  uterus  during  pregnancy  is,  as 
we  have  seen,  chiefly  to  be  explained  by  the  growth  of  its  structures,  all 
of  which  are  modified  during  gestation.  The  peritoneal  covering  is  con- 
siderably increased,  so  as  still  to  form  a  complete  covering  to  the  uterus 
when  at  its  largest  size.  William  Hunter  supposed  that  its  extension 
was  effected  rather  by  the  unfolding  of  the  layers  of  the  broad  ligament 
than  by  growth.  That  the  layers  of  the  broad  ligament  do  unfold  dur- 
ing gestation,  especially  in  the  early  months,  is  probable ;  but  this  is  not 
sufficient  to  account  for  the  complete  investment  of  the  uterus,  and  it  is 
certain  that  the  peritoneum  grows  pari  passu  with  the  enlargement  of 
the  uterus.  In  addition,  there  is  a  new  formation  of  fibrous  tissue 
between  the  peritoneal  and  the  muscular  coats,  which  aifords  strength 
and  diminishes  the  risk  of  laceration  during  labor. 

The  3IuscHlar  Coat. — The  hypertrophy  of  the  muscular  tissue  of  the 
uterus  is,  however^"  the  most  remarkable  of  the  changes  produced  by 
pregnancy.  Not  only  do  the  previously  existing  rudimentary  fibre-cells 
become  enormously  increased  in  size — so  as  to  measure,  according  to 
Kolliker,  from  seven  to  eleven  times  their  former  length  and  from  two 
to  five  times  their  former  breadth — but  new  unstriped  fibres  are  largely 
developed,  especially  in  the  inner  layers.  These  new  cells  are  chiefly 
found  in  the  first  months  of  pregnancy,  and  their  gro^^i:h  seems  to  be 
completed  by  the  sixth  month.  The  connective  tissue  between  the  mus- 
cular layers  is  also  largely  increased  in  amount.  The  weight  of  the 
muscular  tissue  of  the  gravid  uterus  is  therefore  much  increased,  and  it 
has  been  estimated  by  Heschl  that  it  weighs  at  term  from  1  to  1.5  lbs. ; 


PREGNANCY.  139 

that  is,  about  sixteen  times  more  than  in  the  unimpregnated  state.  This 
great  development  of  the  muscular  tissue  admits  of  its  dissection  in  a 
way  which  is  quite  impossible  in  the  unimpregnated  state,  and  the 
researches  of  Helie  (p.  61)  enable  us  to  understand  much  better  than 
before  how  the  muscles  forming  the  walls  of  the  gravid  uterus  act  during 
the  expulsion  of  the  child. 

The  changes  in  the  mucous  coat  of  the  uterus  which  result  in  the  for- 
mation of  the  decidua  have  already  been  discussed  at  length  elsewhere 
(p.  103). 

Circulatory  Apparatus. — The  circulatory  apparatus  of  the  uterus  dur- 
ing pregnancy  has  been  described  when  the  anatomy  of  the  placenta  was 
under  consideration  (p.  111). 

Lymphatics. — The  lymphatics  are  much  increased  in  size,  and  recent 
theories  on  the  production  of  certain  puerperal  diseases  attribute  to 
them  a  more  important  action  than  has  been  commonly  assigned  to 
them. 

Nerves. — The  question  of  the  growth  of  the  nerves  has  been  hotly  dis- 
cussed. Robert  Lee  took  the  foremost  place  among  those  who  main- 
tained that  the  nerves  of  the  uterus  share  the  general  growth  of  its  other 
constituent  parts.  Dr.  Snow  Beck,  however,  believed  that  they  remain 
of  the  same  size  as  in  the  unimpregnated  state ;  and  this  view  is  sup- 
ported by  Hirschfeld,  Robin,  and  other  recent  writers.  Robin  thought 
that  there  is  an  apparent  increase  in  the  size  of  the  nerve-tubes,  which, 
however,  is  really  due  to  increase  in  the  neurilemma.  Kilian  describes 
the  nerves  as  increasing  in  length,  but  not  in  thickness ;  while  Schroeder 
states  that  they  participate  equally  mth  the  lymphatics  in  the  enlarge- 
ment the  latter  undergo.  Whichever  of  these  views  may  ultimately  be 
found  to  be  correct,  it  is  certain  that  analogy  would  lead  us  to  expect  an 
increase  of  nervous  as  well  as  of  vascular  supply. 

General  Modifications  in  the  Body  produced  by  Pregnancy. — It  is  not 
in  the  uterus  alone  that  pregnancy  is  found  to  produce  modifications  of 
importance.  There  are  few  of  the  more  important  functions  of  the  body 
which  are  not,  to  a  greater  or  less  extent,  affected :  to  some  of  these  it  is 
necessary  briefly  to  direct  attention,  inasmuch  as,  when  carried  to  excess, 
they  produce  those  disorders  which  often  complicate  gestation  and  which 
prove  so  distressing  and  even  dangerous  to  the  patients.  Such  of  them 
as  are  apparent  and  may  aid  us  in  diagnosis  are  discussed  in  the  chapter 
which  treats  of  the  signs  and  symptoms  of  pregnancy  :  in  this  place  it 
is  only  necessary  to  refer  to  those  which  do  not  properly  fall  into  that 
category. 

Changeji  in  the  Blood. — Amongst  those  which  are  most  constant  and 
important  are  the  alterations  in  the  composition  of  the  blood.  The 
opinion  of  the  profession  on  this  subject  has  of  late  years  undergone  a 
remarka])le  change.  Formerly  it  was  universally  believed  that  preg- 
nancy was,  as  the  rule,  associated  with  a  condition  analogous  to  j)lethora, 
and  that  this  explained  many  characteristic  phenomena  of  common 
occurrence,  such  as  headache,  palpitation,  singing  in  the  ears,  shortness 
of  breatli,  and  the  like.  As  a  consec^uence,  it  was  the  habitual  custom, 
not  yet  by  any  means  entirely  abandoned,  to  treat  pregnant  women  on 
an  antiphlogistic  system — to  place  them  on  low  diet,  to  administer  low- 


140  PREGNANCY. 

ering  remedies,  and  very  often  to  practise  venesection,  sometimes  to  a 
surprising  extent.  Thus  it  was  by  no  means  rare  for  women  to  be  bled 
six  or  eight  times  during  the  latter  months,  even  when  no  definite  symp- 
toms of  disease  existed ;  and  many  of  the  older  authors  record  cases 
where  depletion  was  practised  every  fortnight  as  a  matter  of  routine,  and 
when  the  symptoms  were  well  marked  even  from  fifty  to  ninety  times, 
in  the  course  of  a  single  pregnancy. 

Composition  of  the  Blood  in  Pregnancy. — Numerous  careful  analyses 
have  conclusively  proved  that  the  composition  of  the  blood  during  preg- 
nancy is  very  generally — perhaps  it  would  not  be  too  much  to  say 
always — profoundly  altered.  Thus  it  is  found  to  be  more  watery,  its 
serum  is  deficient  in  albumen,  and  the  amount  of  colored  globules  is 
materially  diminished,  averaging,  according  to  the  analysis  of  Beccjuerel 
and  Rodier,  111.8  against  127.2  in  the  non-gravid  state.  At  the  same 
time  the  amount  of  fibrin  and  of  extractive  matter  is  considerably 
increased.  The  latter  observation  is  of  peculiar  importance,  as  it  goes 
far  to  explain  the  frequency  of  certain  thrombotic  affections  observed  in 
connection  with  pregnancy  and  delivery  :  this  hyperinosis  of  the  blood 
is  also  considerably  increased  after  labor  by  tlie  quantity  of  effete  mate- 
rial thrown  into  the  mother's  system  at  that  time  to  be  got  rid  of  by  her 
emunctories.  The  truth  is,  that  the  blood  of  the  pregnant  woman  is 
generally  in  a  state  much  more  nearly  approaching  the  condition  of 
ansemia  than  of  plethora,  and  it  is  certain  that  most  of  the  phenomena 
attributed  to  plethora  may  be  explained  equally  well  and  better  on  this 
view.  These  changes  are  much  more  strongly  marked  at  the  latter  end 
of  pregnancy  than  at  its  commencement ;  and  it  is  interesting  to  observe 
that  it  is  then  that  the  concomitant  phenomena  alluded  to  are  most  fre- 
quently met  with.  Cazeaux,  to  whom  we  are  chiefly  indebted  for  insist- 
ing on  the  practical  bearing  of  these  views,  contends  that  the  pregnant 
state  is  essentially  analogous  to  chlorosis,  and  that  it  should  be  so  treated. 
More  recently  the  accurate  observations  of  Willcocks^  have  shown  that 
the  blood  of  pregnancy  differs  from  that  of  chlorosis  in  the  fact  that 
while  in  both  the  amount  of  haemoglobin  is  lessened,  in  pregnancy  the 
individual  blood-cells  are  not  impoverished  as  they  are  in  chlorosis,  but 
simply  lessened  in  comparative  number,  owing  to  an  increase  in  the 
water  of  the  plasma,  due  to  the  progressive  enlargement  of  the  vascular 
area  during  gestation.  Objection  has  not  unnaturally  been  taken  to 
CazeauS's  theory,  as  implying  that  a  healthy  and  normal  function  is 
associated  with  a  morbid  state ;  and  it  has  been  suggested  that  this  dete- 
riorated state  of  the  blood  may  be  a  wise  provision  of  nature  instituted 
for  a  purpose  we  are  not  as  yet  able  to  understand.  It  may  certainly  be 
admitted  that  pregnancy,  in  a  perfectly  healthy  state  of  the  system, 
should  not  be  associated  with  phenomena  in  themselves  in  any  degree 
morbid.  It  must  not  be  forgotten,  however,  that  our  patients  are  sel- 
dom— we  might  safely  say  never — in  a  state  that  is  physiologically 
healthy.  The  influence  of  civilization,  climate,  occupation,  diet,  and  a 
thousand  other  disturbing  causes,  that  to  a  greater  or  less  degree  are 
always  to  be  met  with,  must  not  be  left  out  of  consideration.     INIaking 

^  "  Comparative  Observations  on  the  Blood  in  Chlorosis  and  Pregnancy,"  by  Fred. 
Willcocks,  M.  D.,  The  Lancet,  December  3,  1881. 


PREGNANCY. 


141 


every  allowance,  therefore,  for  the  undoubted  fact  that  pregnancy  ought 
to  be  a  perfectly  healthy  condition,  it  must  be  conceded,  I  think,  that  in 
the  vast  majority  of  cases  coming  under  our  notice  it  is  not  entirely  so ; 
and  the  deductions  drawn  by  Cazeaux  from  the  numerous  analyses 
of  the  blood  of  pregnant  women  seem  to  point  strongly  to  the  conclu- 
sion that  the  general  blood-state  is  tending  to  poverty  and  anaemia,  and 
that  a  depressing  and  antiphlogistic  treatment  is  distinctly  contraindi- 
cated. 

Modifications  in  Certain  Viscera. — Closely  connected  with  the  altered 
condition  of  the  blood  is  the  physiological  hypertrophy  of  the  heart 
which  is  now  well  known  to  occur  during  pregnancy.  This  ^\"as  first 
pointed  out  by  Larcher  in  1828,  and  it  has  been  since  verified  by 
numerous  observers.  It  seems  to  be  constant  and  considerable,  and  to 
be  a  purely  physiological  alteration,  intended  to  meet  the  increased 
exigencies  of  the  circulation  which  the  complex  vascular  arrangements 
of  the  gravid  uterus  produce.  The  hypertrophy  is  limited  to  the  left 
ventricle,  the  right  ventricle,  as  well  as  both  auricles,  being  unaffected. 
Blot  estimates  that  the  whole  weight  of  the  heart  increases  one-fifth 
durino;  testation.  The  more  recent  researches  of  Lohlein^  render  it 
probable  that  the  hypertrophy  is  less  than  those  authors  have  supposed. 
According  to  Duroziez^  the  heart  remains  enlarged  during  lactation,  but 
diminishes  in  size  immediately  after  delivery  in  women  who  do  not 
suckle,  Avhile  in  women  who  have  borne  many  children  it  remains 
permanently  somewhat  larger  than  in  nulliparee.  Similar  increase  in 
the  size  of  other  organs  has  been  pointed  out  by  various  writers  ;  as,  for. 
example,  in  the  lymphatics,  the  spleen,  and  the  liver.  Tarnier  states 
that  in  women  who  have  died  after  delivery  the  organs  always  show 
signs  of  fatty  degeneration.  According  to  Gassner,  the  whole  body 
increases  in  weight  during  the  latter  months  of  pregnancy,  and  this 
increase  is  somewhat  beyond  that  which  can  be  explained  by  the  size 
of  the  womb  and  its  contents. 

Formation  qfOsteoj^kytes. — Irregular  bony  deposits  between  the  skull 
and'TEe^TTura  mater,  in  some  cases  so  largely  developed  as  to  line  the 
whole  cranium,  have  been  so  frequently  detected  in  women  who  have 
died  during  parturition  that  they  are  believed  by  some  to  be  a  normal 
production  connected  with  pregnancy.  Ducrest  found  these  osteophytes 
in  more  than  one-third  of  the  cases  in  which  he  performed  post-mortem 
examinations  during  the  puerperal  period.  Rokitansky,  who  corrobo- 
rated the  observation,  believed  this  peculiar  deposit  of  bony  matter  to 
be  a  physiological  and  not  a  pathological  condition  connected  with 
pregnancy ;  but  whether  it  be  so,  or  how  it  is  produced,  has  not  yet 
been  satisfactorily  determined. 

Chanj/esin  the  Nervous  System. — More  or  less  marked  changes  con- 
nccted  wHmhe  nervous  system  are  generally  observed  in  pregnancy, 
and  sometimes  to  a  very  great  extent.  When  carried  to  excess  they 
l^roduce  some  of  the  most  troublesome  disorders  Avhich  complicate 
gestation,  such  as  alterations  in  the  intellectual  functions,  changes  in 
the  disposition  and  character,  morbid  cravings,  dizziness,  neuralgia, 
syncope,  and  many  others.     They  are  purely  functional  in  their  clia- 


r 


^  ZeilHchrlJlfur  Geburi«hiilfe,  etc.,  1H76. 


2  Goz.  (les  HSpiL,  18G8. 


142  PREGNANCY. 

racter,  and  disappear  rapidly  after  delivery,  and  may  be  best  described 
in  connection  with  the  disorders  of  pregnancy. 

Changes  in  the  Respiratory  Organs. — Respiration  is  often  interfered 
with,  from  the  mechanical  results  of  the  pressure  of  the  enlarged  uterus. 
The  longitudinal  dimensions  of  the  thorax  are  lessened  by  the  ujjward 
displacement  of  the  diaphragm,  and  this  necessarily  leads  to  some 
embarrassment  of  the  respiration,  which  is,  however,  com])ensated,  to 
a  great  extent,  by  an  increase  in  breadth  of  the  base  of  the  thoracic 
cavity. 

Changes  in  the  Urine. — Certain  changes,  which  are  of  very  constant 
occurrence,  in  the  urine  of  pregnant  women  have  attracted  much  atten- 
tion, and  have  been  considered  by  many  writers  to  be  pathognomonic. 
They  consist  in  the  presence  of  a  peculiar  deposit,  formed  when  the 
urine  has  been  allowed  to  stand  for  some  time,  which  has  received  the 
name  of  Me  stein.  Its  presence  was  known  to  the  ancients,  and  it  was 
particularly  mentioned  by  Savonarola  in  the  fifteenth  century,  but  it 
has  more  especially  been  studied  within  the  last  thirty  years  by  Eguisier, 
Golding  Bird,  and  others.  If  the  urine  of  a  pregnant  woman  be  allowed 
to  stand  in  a  cylindrical  vessel,  exposed  to  light  and  air,  but  protected 
from  dust,  in  a  period  varying  from  two  to  seven  days,  a  peculiar 
flocculent  sediment,  like  fine  cotton  wool,  makes  its  appearance  in  the 
centre  of  the  fluid,  and  soon  afterward  rises  to  the  surface  and  forms  a 
pellicle,  which  has  been  compared  to  the  fat  on  cold  mutton-broth. 
In  the  course  of  a  few  days  the  scum  breaks  up  and  falls  to  the  bottom 
of  the  vessel.  On  microscopic  examination  it  is  found  to  be  composed 
of  fat  particles,  with  crystals  of  ammoniaco-magnesium  phosphates  and 
phosphate  of  lime  and  a  large  quantity  of  vibriones.  These  appearances 
are  generally  to  be  detected  after  the  second  month  of  pregnancy,  and 
up  to  the  seventh  or  eighth  month,  after  which  they  are  rarely  produced. 
Regnauld  explains  their  absence  during  the  latter  months  of  gestation 
by  the  presence  in  the  urine  at  that  time  of  free  lactic  acid,  M'hich 
increases  its  acidity  and  prevents  the  decomposition  of  the  urea  into 
carbonate  of  ammonia.  He  believes  that  kiestein  is  produced  by  the 
action  of  free  carbonate  of  ammonia  on  the  phosphate  of  lime  con- 
tained in  the  urine,  and  that  this  reaction  is  jDrevented  by  the  excess 
of  acid, 

Golding  Bird  believed  kiestein  to  be  analogous  to  casein,  to  the 
presence  of  which  he  referred  it,  and  he  states  that  he  has  found  it  in 
twenty-seven  out  of  thirty  cases.  Braxton  Hicks  so  far  corroborates 
his  view,  and  states  that  the  deposit  of  kiestein  can  be  mucli  more 
abundantly  produced  if  one  or  two  teaspoonfuls  of  rennet  be  added  to 
the  urine,  since  that  substance  has  the  property  of  coagulating  casein. 
Much  less  importance,  however,  is  now  attached  to  the  presence  of 
kiestein  than  formerly,  since  a  precisely  similar  substance  is  sometimes 
found  in  the  urine  of  the  non-pregnant,  especially  in  ansemic  women, 
and  even  in  the  lu'ine  of  men.  Parkes  states  that  it  is  not  of  uniform 
composition — that  it  is  produced  by  the  decomposition  of  urea,  and 
consists  of  the  free  phosphates,  bladder  mucus,  infusoria,  and  vaginal 
discharges.  I^eugebauer  and  Vogel  give  a  similar  account  of  it,  and 
hold  that  it  is  of  no  diagnostic  value.     That  it  is  of  interest,  as  indi- 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  '  143 

eating  the  changes  going  on  in  connection  with  pregnancy,  is  certain ; 
but  inasmuch  as  it  is  not  of  invariable  occurrence,  and  may  even  exist 
quite  independently  of  gestation,  it  is  obviously  quite  undeserving  of 
the  extreme  importance  that  has  been  attached  to  it. 

[Although  not  a  reliable  test  of  pregnancy,  it  is  a  remarkable  fact 
that  in  all  the  cases  of  suspected  pregnancy  in  private  practice  in  which 
I  have  employed  it  I  never  found  a  woman  who  proved  to  be  impreg- 
nated in  whose  urine  it  did  not  appear.  When  Dr.  Kane  Avas  preparing 
his  thesis  on  kiestein  he  examined  a  large  number  of  specimens  of  urine 
and  considered  the  test  a  good  one ;  but  the  fact  that  it  may  be  found 
in  the  urine  of  the  non-pregnant  destroys  its  reliability  for  general  use 
in  diagnosis. — Ed.] 

(T^/co£wr^£)i^P>-£;g«anc3/. — Toward  the  end  of  pregnancy  sugar  may 
sometimes  be  detected  iii~tlie  urine,  and  after  delivery  and  during  lacta- 
tion it  exists  in  considerable  abundance ;  thus,  out  of  thirty-five  cases 
tested  in  the  Simpson  Memorial  Hospital  in  Edinburgh  during  the 
puerperium,  it  was  found  in  all,  the  amount  varying  from  1  to  8  per 
cent.^  Kaltenbach  has  shown  that  this  temporary  glycosuria  is  due  to 
the  presence  of  milk-sugar  in  the  urine,  and  that  it  ceases  with  the 
disappearance  of  milk  from  the  breasts.^  This  physiological  glycosuria  \ 
must  be  carefully  distinguished  from  true  diabetes,  which  is  a  grave  I 
complication  of  pregnancy.  • 


CHAPTER   IV. 

SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

Importance  of  the  Subject. — In  attempting  to  ascertain  the  presence  or 
absence  of  pregnancy  the  practitioner  has  before  him  a  problem  which 
is  often  beset  with  great  difficulties,  and  on  the  proper  solution  of  which 
the  moral  character  of  his  patient,  as  well  as  his  own  professional  repu- 
tation, may  depend.  The  patient  and  her  friends  can  hardly  be  expected 
to  appreciate  the  fact  that  it  is  often  far  from  easy  to  give  a  positive 
opinion  on  the  point ;  and  it  is  always  advisable  to  use  much  caution 
in  the  examination,  and  not  to  commit  ourselves  to  a  positive  opinion, 
except  on  the  most  certain  grounds.  This  is  all  the  more  important 
because  it  is  just  in  those  cases  in  which  our  opinion  is  most  fre- 
quently asked  that  the  statements  of  tJie  patient  are  of  least  value,  as 
she  is  either  anxious  to  conceal  the  existence  of  pregnancy,  or,  if  desirous 
of  an  affirmative  diagnosis,  unconsciously  colors  her  statements,  so  as  to 
bias  the  judgment  of  the  examiner. 

Classification. — Constant  attempts  have  been  made  to  classify  the  signs 

of  pregnancy  :  thus,  some  divide  tliem  into  the  natural  and  sensible  si^ns, 

others  into  the  presumptive,  the  probable,  and  the  certain.      The  latter 

classification,  which  is  that  adopted  by  Montgomery  in  his  classical  work 

'  Edin.  Med.  Journ.,  Aug.,  1881.         ''ZelLf.  GymeL,  September  13,  1879. 


144  PREGNANCY. 

on  the  Signs  and  Si/mptoms  of  Pregnancy,  is  no  doubt  the  better  of  the 
two,  if  any  be  required.  The  simjilest  way  of  studying  the  subject, 
however,  is  the  one  now  generally  adopted,  of  considering  the  signs  of 
pregnancy  in  the  order  in  which  they  occur,  and  attaching  to  each  an 
estimate  of  its  diagnostic  value. 

Signs  of  a  Fruitful  Conception. — From  the  earliest  ages  authors  have 
thought  that  the  occurrence  of  conception  might  be  ascertained  by  cer- 
tain obscure  signs,  such  as  a  peculiar  appearance  of  the  eyes,  swelling  of 
the  neck,  or  by  unusual  sensations  connected  with  a  fruitful  intercourse. 
All  of  these,  it  need  hardly  be  said,  are  far  too  uncertain  to  be  of  the 
slightest  value.  The  last  is  a  symptom  on  which  many  married  women 
profess  themselves  able  to  depend,  and  one  to  which  Cazeaux  is  inclined 
to  attach  some  importance. 

Cessation  qf_MenstniaMon. — The  first  appreciable  indication  of  preg- 
nancy on  which  any  dependence  can  be  placed  is  the  cessation  of  the 
customary  menstrual  discharge,  and  it  is  of  great  importance,  as  forming 
the  only  reliable  guide  for  calculating  the  probable  period  of  delivery. 
In  women  who  have  been  previously  perfectly  regular,  in  whom  there  is 
no  morbid  cause  which  is  likely  to  have  produced  suppression,  the  non- 
appearance of  the  catamenia  may  be  taken  as  strong  presumptive  evi- 
dence of  the  existence  of  pregnancy  ;  but  it  can  never  be  more  than  this, 
unless  verified  and  strengthened  by  other  signs,  inasmuch  as  there  are 
many  conditions  besides  pregnancy  which  may  lead  to  its  non-appear- 
ance. Thus,  exposure  to  cold,  mental  emotion,  general  debility,  espe- 
cially when  connected  with  incipient  phthisis,  may  all  have  this  effect. 
Mental  impressions  are  peculiarly  liable  to  mislead  in  this  respect.  It 
is  far  from  uncommon  in  newly-married  women  to  find  that  menstru- 
ation ceases  for  one  or  more  periods,  either  from  the  general  disturbance 
of  the  system  connected  with  the  married  life  or  from  a  desire  on  the 
part  of  the  patient  to  find  herself  pregnant.  Also  in  unmarried  women 
who  have  subjected  themselves  to  the  risk  of  impregnation  mental 
emotion  and  alarm  often  produce  the  same  result. 

Menstruation  during  Pregnancy. — A  further  source  of  uncertainty 
exists  in  the  fact  that  in  certain  cases  menstruation  may  go  on  for  one 
or  more  periods  after  conception,  or  even  during  the  whole  pregnancy. 
The  latter  occurrence  is  certainly  of  extreme  rarity,  but  one  or  two  in- 
stances are  recorded  by  Perfect,  Churchill,  and  other  writers  of  authority, 
and  therefore  its  possibility  must  be  admitted.  The  former  is  much  less 
uncommon,  and  instances  of  it  have  probably  come  under  the  observation 
of  most  practitioners.  The  explanation  is  now  well  understood.  During 
the  early  months  of  gestation,  when  the  ovum  is  not  yet  sufficiently 
advanced  in  growth  to  fill  the  Avhole  uterine  cavity,  there  is  a  considerable 
space  between  the  deciclua  reflexa  which  surrounds  it  and  the  decidua 
vera  lining  the  uterine  cavity.  It  is  from  this  free  surface  of  the  decidua 
vera  that  the  periodical  discharge  comes,  and  there  is  not  only  ample 
surface  for  it  to  come  from,  but  a  free  channel  for  its  escape  through 
the  OS  uteri.  After  the  third  month  the  decidua  reflexa  and  the  decidua 
vera  blend  together,  and  the  space  between  them  disappears.  Menstru- 
ation after  this  time  is  therefore  much  more  difficult  to  account  for.  It 
is  probable  that  in  many  supposed  cases  occasional  losses  of  blood  from 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  145 

other  sources,  such  as  placenta  prsevia,  an  abraded  cervix  uteri,  or  a 
small  polypus,  have  been  mistaken  for  true  menstruation.  If  the  dis- 
charge really  occurs  periodically  after  the  third  month,  it  can  only  come 
from  the  canal  of  the  cervix.  The  occurrence,  however,  is  so  rare  that 
if  a  woman  is  menstruating  regularly  and  normally  who  believes  herself 
to  be  more  than  four  months  advanced  in  pregnancy,  we  are  justified 
ipso  facto  in  negativing  her  supposition.  In  an  unmarried  woman  all 
statements  as  to  regularity  of  menstruation  are  absolutely  valueless,  for 
in  such  cases  nothing  is  more  common  than  for  the  patient  to  make  false 
statements  for  the  express  purpose  of  deception. 

Pregnancy  sometimes  occurs  when  Me.]islr nation  is  normally  Absent. — 
Conception  may  unquestionably  occur  when  menstruation  is  normally 
absent.  This  is  far  from  uncommon  in  women  during  lactation,  when 
the  function  is  in  abeyance,  and  who  therefore  have  no  reliable  data  for 
calculating  the  true  period  of  their  delivery.  Authentic  cases  are  also 
recorded  in  which  young  girls  have  conceived  before  menstruation  is 
established,  and  in  which  pregnancy  has  occurred  after  the  change  of  life. 

Estimate  of  its  Diagnostic  Value. — Taking  all  these  facts  into  account, 
we  can  only  look  upon  the  cessation  of  menstruation  as  a  fairly  pre- 
sumptive sign  of  pregnancy  in  women  in  whom  there  is  no  clear  reason 
to  account  for  it,  but  one  which  is  undoubtedly  of  great  value  in 
assisting  our  diagnosis. 

Siimpathetic  DisturbaTwes. — Shortly  after  conception  various  sympa- 
thetic disturbances  of  the  system  occur,  and  it  is  only  very  exceptionally 
that  these  are  not  established.  They  are  generally  most  developed  in 
women  of  highly  nervous  temperament ;  and  they  are,  therefore,  most 
marked  in  patients  in  the  upper  classes  of  society,  in  whom  this  kind  of 
organization  is  most  common. 

Morning  Sickness. — Amongst  the  most  frequent  of  these  are  various 
disorders  of  the  gastro-intestinal  canal.  Nausea  or  vomiting  is  very 
common ;  and  as  it  is  generally  felt  on  first  rising  from  the  recumbent 
position,  it  is  popularly  known  amongst  women  as  the  "  morning  sick- 
ness." It  sometimes  commences  almost  immediately  after  conception, 
but  more  frequently  not_until  the  second  mouthy  and  it  rarely  lasts  after 
the  fourth  month.  Generally  there  is  nausea  rather  than  actual  vomit- 
ing. The  woman  feels  sick  and  unable  to  eat  her  breakfast,  and  often 
brings  xx^  some  glairy  fluid.  In  other  cases  she  actually  vomits ;  and 
sometimes  the  sickness  is  so  excessive  as  to  resist  all  treatment,  seriously 
to  affect  the  patient's  health,  and  even  imperil  her  life.  These  grave 
forms  of  the  affection  will  require  separate  consideration. 

Cause  of  the  Sickness. — Very  different  opinions  have  been  held  as  to 
the  cause  of  morning  sickness.  Dr.  Henry  Bennet  believes  that  when 
at  all  severe  it  is  always  associated  with  congestion  and  inflammation  of 
the  cervix  uteri.  Dr.  Graily  Hewitt  maintains  that  it  depends  entirely 
on  flexion  of  the  uterus,  producing  irritation  of  the  uterine  nerves  at  the 
seat  of  tlie  flexion,  and  consccjuent  sympathetic  vomiting.  This  tlieory, 
when  broached  at  the  C)[)steti'ical  Socaety,  was  received  with  little  favor : 
it  seems  to  me  to  l)e  sufficiently  disjiroved  by  the  fact,  which  I  believe 
to  be  certain,  that  more  or  less  nausea  is  a  normal  and  nearly  constant 
phenom(;non  in  jorcgnancy,  for  it  is  difficult  to  believe  that  nearly  every 


146  PREGNANCY. 

pregnant  woman  has  a  flexed  uterus.  Tlie  generally  received  explanation 
is  probably  the  correct  one — viz.  that  nausea,  as  well  as  other  forms  of 
sympathetic  disturbance,  depends  on  the  stretching  of  the  uterine  fibres 
by  the  growing  ovum,  and  consequent  irritation  of  the  uterine  nerves. 
It  is,  therefore,  one,  and  only  one,  of  the  numerous  reflex  phenomena  nat- 
urally accompanying  pregnancy.  It  is  an  old  observation  that  when  the 
sickness  of  pregnancy  is  entirely  absent,  other,  and  generally  more  dis- 
tressing, sympathetic  derangements  are  often  met  with,  such  as  a  tendency 
to  syncope.  Dr.  Bedford '  has  laid  especial  stress  on  this  point,  and  main- 
tains that  under  >;uch  circumstances  Avomen  are  peculiarly  apt  to  miscarry. 

Other  (J('r((ii(/ciii('iit.s  of  the  digestive  Junctions,  depending  on  the  same 
cause,  are  not  uncommon,  such  as  excessive"  or  depraved  appetite,  the 
patient  showing  a  craving  for  strange  and  even  disgusting  articles  of  diet. 
These  cravings  may  be  altogether  irresistible,  and  are  popularly  known 
^^  'll2i?SlBS^-"  ^f  ^  similar  character  is  the  disturbed  condition  of  the 
bowels  frequently  observed,  leading  to  constipation,  diarrhoea,  and  exces- 
i   sive  flatulence. 

1  Other  Sympathetie  Phenomena. — Certain  glandular  sympathies  may  be 
developed,  one  of  the  most  common  being  an  excessive  secretion  from 
I  the  salivary  glands.  A  tendency  to  syncope  is  not  infrequent,  rarely 
proceeding  to  actual  fainting,  but  rather  to  that  sort  of  partial  syncope, 
unattended  with  complete  loss  of  consciousness,  which  the  older  authors 
used  to  call  "  lypothaemia."  This  often  occurs  in  women  who  show  no 
such  tendency  at  other  times,  and  when  developed  to  any  extent  it  forms 
a  very  distressing  accompaniment  of  pregnancy.  Toothache  is  common, 
and  is  not  rarely  associated  with  actual  caries  of  the  teeth.  When  any 
of  these  phenomena  are  carried  to  excess,  it  is  more  than  probable  that 
some  morbid  condition  of  the  uterus  exists  wliich  increases  the  local 
irritation  producing  them. 

Mental  Peculiarities. — Mental  phenomena  are  very  general.  An  undue 
degree  of  despondency,  utterly  beyond  the  patient's  control,  is  far  from 
uncommon ;  or  a  change  which  renders  the  bright  and  good-tempered 
woman  fractious  and  irritable ;  or  even  the  more  fortunate  but  less  com- 
mon change,  by  which  a  disagreeable  disposition  becomes  altered  for  the 
/  better. 

The  Diagnostic  Value  of  these  Sympathetie  Disturbances  is  Small. — 
All  these  phenomena  of  exalted  nervous  susceptibility  are  but  of  slie::ht 
diagnostic  value.  They  may  be  taken  as  corroborating  more  certain 
signs,  but  nothing  more,  and  they  are  chiefly  interesting  from  their  tend- 
ency to  be  carried  to  excess  and  to  produce  serious  disorders. 

Mammary  Changes. — Certain  changes  in  the  mammse  are  of  early 
occurrence,  de}KMident,  no  doubt,  on  the  intimate  sympathetic  relations 
at  all  times  existing  between  them  and  the  uterine  organs,  but  chiefly 
required  for  the  purpose  of  preparing  for  the  important  function  of  lac- 
tation, which  on  the  termination  of  pregnancy  they  have  to  perform. 

Chmu/es  in  the  Areoke. — Generally  about  the  second  month  of  preg- 
nancy the  breasts  become  increased  in  size  and  tender.  As  pregnancy 
advances  they  become  much  larger  and  firmer,  and  blue  veins  may  be 
seen  coursing  over  them.     The  most  characteristic  changes  are  about  the 

^  Diseases  of  Women  and  Children,  p.  551. 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  147 

nipples  and  areolae.  The  nipples  become  turgid,  and  are  frequently  cov- 
ered with  minute  branny  scales,  formed  by  the  desiccation  of  sero-lactes- 
cent  fluid  oozing  from  them.  The  areolae  become  greatly  enlarged  and 
darkened  from  the  deposit  of  pigment  (Fig.  79).  The  extent  and  degree 
of  this  discoloration  vary  much  in  different  women.  In  fair  women  it 
may  be  so  slight  as  to  be  hardly  appreciable,  while  in  dark  women  it  is 

Fig.  79. 


/ 


Appearance  of  the  Areola  in  Pregnancy. 


generally  exceedingly  characteristic,  sometimes  forming^  a  nearly  black 
circle  extending  over  a  great  part  of  the  breast.     The  areola  becomes 
moist  as  well  as  dark  in  appearance,  and  is  somewhat  swollen,  and  a 
number  of  small  tubercles  are  developed  upon  it,  forming  a  circle  of 
projections  round  the  nipple.     These  tubercles  are  describecl  by  Mont- 
gomery as  being  intimately  connected  with  the  lactiferous  ducts,  some 
of  which  may  occasionally  be  traced  into  them  and  seem  to  open  on  their 
summits.     As  pregnancy  advances  they  increase  in  size  and  number.  \ 
During  the  latter  months  what  has  been  called  ''  the  secQiidary_areQ]a  "J_ 
is  produced,  and  when  well  marked  presents  a  very  characteristic  appear- 
ance.    It  consists  of  a  number  of  minute  discolored  spots  all  round  the'! 
outer  margin  of  the  areola,  where  the  pigmentation  is  fainter,  and  which  | 
are  generally  described  as  resembling  spots  from  which  the  color  has  [ 
been  discharged  by  a  shower  of  water-drops.     Tliis  change,  like  i\\€ 
darkening  of  the  ]^rimary  areola,  is  more  marked  in  brunettes.     At  this 
jieriod,  especially  in  women  whoso  skin  is  of  fine  texture,  whitish  silvery 
sti-caks  are  often  seen  on  the  breasts.     They  are  produced  l)y  the  stretch- 
ing of  the  cutis  vera,  and  are  permanent. 

By  pressure  on  the  breasts  a  small  drop  of  serous-looking  fluid  can 
very  generally  be  forced  out  from  the  ni])ple,  often  as  early  as  the  third 
month,  and  on  microscopic  examination  milk  and  cholostrum-globules 
can  be  seen  in  it. 


148  PREGNANCY. 

Diagnostic  Value  of  Mammary  Chrniges. — The  diagnostic  value  of 
these  mammary  clianges  has  been  variously  estimated.  When  well 
marked  they  are  considered  by  Montgomery  to  be  certain  signs  of  preg- 
nancy. To  this  statement,  however,  some  important  limitations  must  be 
made.  In  women  who  have  never  borne  children  they  no  doubt  are  so  ; 
for,  although  various  uterine  and  ovarian  diseases  produce  some  darken- 
ing of  the  areola,  they  certainly  never  produce  the  well-marked  changes 
above  described.  In  multipara,  however,  the  areolae  often  remain  per- 
manently darkened,  and  in  them  these  signs  are  much  less  reliable.  In 
first  pregnancies  the  presence  of  milk  in  the  breasts  may  be  considered 
an  almost  certain  sign,  and  it  is  one  which  I  have  rarely  failed  to  detect 
even  from  a  comjDaratively  early  period.  It  is  true  that  there  are  authen- 
ticated instances  of  non-pregnant  women  having  an  abundant  secretion 
of  milk  established  from  mammary  irritation.  Thus,  Baudelocque  pre- 
sented to  the  Academy  of  Surgery  of  Paris  a  young  girl,  eight  years  of 
age,  who  had  nursed  her  little  brother  for  more  than  a  month.  Dr. 
Tanner  states — I  do  not  know  on  what  authority — that "  it  is  not  uncom- 
mon in  Western  Africa  for  young  girls  who  have  never  been  pregnapt  to 
regularly  employ  themselves  in  nursing  the  children  of  others,  the  mam- 
mae being  excited  to  action  by  the  application  of  the  juice  of  one  of  the 
Euphorbiacepe."  Lacteal  secretion  has  even  been  noticed  in  the  male  breast. 
But  these  exceptions  to  the  general  rule  are  so  uncommon  as  merely  to 
deserve  mention  as  curiosities ;  and  I  have  hardly  ever  been  deceived  in 
diagnosing  a  first  pregnancy  from  the  presence  of  even  the  minutest 
quantity  of  lacteal  secretion  in  the  breasts,  although  even  then  other 
corroborative  signs  should  always  be  sought  for.  In  multiparse  the  pres- 
ence of  milk  is  by  no  means  so  valuable,  for  it  is  common  for  milk  to 
remain  in  the  mammse  long  after  the  cessation  of  lactation,  even  for  sev- 
eral years.  Tyler  Smith  correctly  says  that  "  suppression  of  the  milk 
in  persons  who  are  nursing  and  liable  to  impregnation  is  a  more  valua- 
ble sign  of  pregnancy  than  the  converse  condition."  This  is  an  observa- 
tion I  have  frequently  corroborated. 

As  a  diagnostic  sign,  therefore,  the  mammary  appearances  are  of  great 
importance  in  primiparse,  and  when  ^^ell  marked  they  are  seldom  likely 
to  deceive.  They  are  specially  important  when  we  suspect  pregnancy  in 
the  unmarried,  as  we  can  easily  make  an  excuse  to  look  at  the  breast 
without  explaining  to  the  jDatient  the  reason  ;  and  a  single  glance,  espe- 
cially if  the  patient  be  dark-complexioned,  may  so  far  strengthen  our  sus- 
picion as  to  justify  a  more  thorough  examination.  In  married  multiparge 
they  are  less  to  be  depended  upon. 

Other  Pigmentary  Chamges. — In  connection  with  this  subject  may  be 
menTioned  various  irregular  deposits  of  pigment  which  are  frequently 
observed.  The  most  common  is  a  dark-brownish  or  yellowish  line  start- 
ing from  the  pubes  and  running  up  to  the  centre  of  the  abdomen,  some- 
times as  far  as  the  umbilicus  only,  at  others  forming  an  irregular  ring- 
round  the  umbilicus  aiid  reaching  to  the  epigastrium.  It  is,  however, 
of  very  uncertain  occurrence,  being  ^\e\\  marked  in  some  women,  M'hile 
in  others  it  is  entirely  absent.  Patches  of  darkened  skin  are  often 
observed  about  the  face,  chiefly  on  the  forehead,  and  this  bronzing  some- 
times gives  a  very  peculiar  appearance.    Joulin  states  that  it  only  occurs 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  149 

on  parts  of  the  face  exposed  to  the  sun,  and  that  it  is  therefore  most  fre- 
quently observed  in  women  of  the  lower  order  who  are  freely  exposed  to 
atmospheric  influences.  These  pigmentary  changes  are  of  small  diag- 
nostic value,  and  may  continue  for  a  considerable  time  after  delivery. 

Enlargement  of  the  Abdoimn. — The  progressive  enlargement  of  the 
abdoTnen  and  the  size  of  the  gravid  uterus  at  various  periods  of  preg- 
nancy, as  well  as  the  method  of  examination  by  means  of  abdominal 
palpation,  have  already  been  described  (pp.  124  and  134). 

AV'e  will  now  consider  the  well-known  phenomena,  produced  by  the 
movements  of  the  foetus  in  utero,  which  are  so  familiar  to  all  pregnant 
women.  These,  no  doubt,  take  place  from  the  earliest  jDeriod  of  foetal 
life  at  which  the  muscular  tissue  of  the  foetus  is  sufficiently  developed  to 
admit  of  contraction,  but  they  are  not  felt  by  the  mother  until  some- 
where about  the  sixteenth  week  of  utero-gestation,  the  precise  period  at 
which  they  are  perceived  varying  considerably  in  different  cases.  The 
error  of  the  law  on  this  subject,  which  supposes  the  child  not  to  be 
alive,  or  "  quick,"  until  the  mother  feels  its  movements,  is  well  known, 
and  has  frequently  been  protested  against  by  the  medical  profession. 

Quickening. — The  so-called  quickening — which  certainly  is  felt  very 
suddenly  by  some  women — is  believed  to  depend  on  the  rising  of  the 
uterine  tumor  sufficiently  high  to  permit  of  the  impulse  of  the  foetus 
being  transmitted  to  the  abdominal  walls  of  the  mother,  through  the 
sensory  nerves  of  which,  its  movements  become  appreciable.  The  sensa- 
tion is  generally  described  as  being  a  feeble  fluttering,  which  when  first 
felt  not  unfrequently  causes  unpleasant  nervous  sensations.  As  the 
uterus  enlarges  the  movements  become  more  and  more  distinct,  and  gen- 
erally consist  of  a  series  of  sharp  blows  or  kicks,  sometimes  quite  appre- 
ciable to  the  naked  eye  and  causing  distinct  projections  of  the  abdominal 
walls.  Their  force  and  frequency  will  also  vary  during  pregnancy  ac- 
cording to  circumstances.  At  times  they  are  very  frequent  and  distress- 
ing ;  at  others  the  foetus  seems  to  be  comparatively  quiet,  and  they  may 
even  not  be  felt  for  several  days  in  succession,  and  thus  unnecessary  fears 
as  to  the  death  of  the  foetus  often  arise.  The  state  of  the  mother's  health 
has  an  undoubted  influence  upon  them.  They  are  said  to  increase  in 
force  after  a  prolonged  abstinence  from  food  or  in  certain  positions  of 
the  body.  It  is  certain  that  causes  interfering  with  the  vitality  of  the 
foetus  often  produce  very  irregular  and  tumultuous  movements.  They 
can  be  very  readily  felt  by  the  accoucheur  on  palpating  the  abdomen, 
and  sometimes,  in  the  latter  months,  so  distinctly  as  to  leave  no  doubt 
as  to  the  existence  of  pregnancy.  They  can  also  generally  be  induced 
by  placing  one  hand  on  each  side  of  the  abdomen  and  applying  gentle 
pressure,  which  will  induce  foetal  motion  that  can  be  easily  appreciated. 

The  Blar/nostic  .Yfjlue  ol  Fqetal  Movements. — As  a  diagnostic  sign  the 
existence  of  foetal  movements  has  always  held  a  high  place,  but  care 
should  be  taken  in  relying  on  it.  It  is  certain  that  women  are  them- 
selves very  often  in  error,  and  fancy  they  feel  the  movements  of  a  foetus 
when  none  exists,  being  probably  deceived  by  irregular  contractions  of 
the  a1:)dominal  muscles  or  flatus  within  the  Ijowels.  They  may  even 
involuntarily  produce  such  intra-abdominal  movements  as  may  readily 


1 50  PREGNANCY. 

deceive  the  practitioner.  Of  course  in  advanced  prpgnancy^  wlien  the 
foetal  movements  are  so  marked  as  to  be  seen  as  well  as  felt,  a  mistake 
is  hardly  possible,  and  they  then  constitute  a  certain  sign.  But  in  such 
cases  there  is  an  abundance  of  other  indications  and  little  room  for 
doubt.  In  questionable  cases,  and  at  an  early  period  of  pregnancy,  the 
fact  that  movements  are  not  felt  must  not  be  taken  as  a  proof  of  the 
non-existence  of  pregnancy,  for  they  may  be  so  feeble  as  not  to  be  per- 
ceptible, or  they  may  be  absent  for  a  considerable  period. 

Intermittent  Uterine  (hntr  act  ions. — Braxton  Hicks  ^  has  directed  atten- 
tion to  the  value,  from  a  diagnostic  point  of  view,  of  intermittent  con- 
tractions of  the  uterus  during  pregnancy.  After  the  uterus  is  suflfieiently 
large  to  be  felt  by  palpation,  if  the  hand  be  placed  over  it  and  it  be 
grasped  for  a  time  without  using  any  friction  or  pressure,  it  will  be 
observed  to  distinctly  harden  in  a  manner  that  is  quite  characteristic. 

This  intermittent  contraction  occurs  every  five  or  ten  minutes,  some- 
times oftener,  rarely  at  longer  intervals.  The  fact  that  the  uterus  did 
contract  in  this  way  had  been  previously  described,  more  especially  by 
Tyler  Smith,  who  ascribed  it  to  peristaltic  action.  But  it  is  certain  that 
no  one,  before  Dr.  Hicks,  had  pointed  out  the  fact  that  such  contractions 
are  constant  and  normal  concomitants  of  pregnancy,  continuing  during 
the  whole  period  of  utero-gestation,  and  forming  a  ready  and  reliable 
means  of  distinguishing  the  uterine  tumor  from  other  abdominal  enlarge- 
ments. Since  reading  Dr.  Hicks's  paper  I  have  paid  considerable 
attention  to  this  sign,  which  I  have  never  failed  to  detect,  even  in  the 
retroverted  gravid  uterus  contained  entirely  in  the  pelvic  cavity,  and  I 
am  disposed  entirely  to  agree  with  him  as  to  its  great  value  in  diagnosis. 
If  the  hand  be  kept  steadily  on  the  uterus,  its  alternate  hardening  and 
relaxation  can  be  appreciated  with  the  greatest  ease.  The  advantages 
which  this  sign  has  over  the  foetal  movements  are  that  it  is  constant, 
that  it  is  not  liable  to  be  simulated  by  anything  else,  and  that  it  is  inde- 
pendent of  the  life  of  the  child,  being  equally  appreciable  when  the 
uterus  contains  a  degenerated  ovum  or  dead  foetus.  The  only  condition 
likely  to  give  rise  to  error  is  an  enlargement  of  the  uterus  in  consequence 
of  contents  other  than  the  results  of  conception,  such  as  retained  menses 
or  a  polypus.  The  history  of  such  cases — which  are,  moreover,  of 
extreme  rarity — would  easily  prevent  any  mistake.  As  a  corroborative 
sign  of  pregnancy,  therefore,  I  should  give  these  intermittent  contrac- 
tions a  high  place.  [I  once  attended  the  wife  of  a  physician  in  her  sec- 
ond pregnancy,  who  had  lost  her  first  child  by  abortion,  and  was  sup- 
posed to  be  again  threatened  with  the  same  misfortune.  I  found  her 
suffering  pain  with  each  intermittent  contraction,  but  beyond  this  there 
Avere  no  symptoms  to  indicate  an  expulsive  design  on  the  part  of  the 
uterus.  These  painful  intermittent  contractions  persisted  for  three 
weeks,  and  then  gradually  assumed  their  normal  character  under  an  opi- 
ate treatment.  The  lady  went  to  the  full  term  of  gestation  and  bore  a 
child  which  lived. — Ed.] 

Vaginal  Signs  of  Pregnancy. — The  vaginal  signs  of  pregnancy  are  of 
considera ble  importance  liTTliagnosis.      They  are  chiefly  the  changes 

1  Obst.  Trans.,  v.  13. 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  151 

which  may  be  detected  in  the  cervix,  and  the  so-called  ballottement, 
which  depends  on  the  mobility  of  the  foetus  in  the  liquor  amnii. 

Sa^emn£  of_  the  Cervix. — The  alterations  in  the  density  and  apparent 
length  of  the  cervix  have  been  already  described  (p.  137).  When  preg-i 
nancy  has  advanced  beyond  the  fifth  month  the  peculiar  velvety  soft-| 
ness  "of  the  cervix  is  very  characteristic,  and  aifords  a  strong  corrobora-^ 
tive  sign,  but  one  which  it  would  be  unsafe  to  rely  on  by  itself,  inasmuch 
as  very  similar  alterations  may  be  produced  by  various  causes.  When, 
however,  in  a  supposed  case  of  pregnancy  advanced  beyond  the  period 
indicated,  the  cervix  is  found  to  be  elongated,  dense,  and  projecting  into 
the  vaginal  canal,  the  non-existence  of  pregnancy  may  be  safely  inferred. 
Therefore  the  negative  value  of  this  sign  is  of  more  importance  than  the 
positive. 

Bqllottement — Ballottement,  when  distinctly  made  out,  is  a  very  val- 
uable indication  of  pregnancy.  It  consists  in  the  displacement,  by  the 
examining  finger,  of  the  foetus,  which  floats  up  in  the  liquor  amnii,  and 
falls  back  again  on  the  tip  of  the  finger  with  a  slight  tap  which  is 
exceedingly  characteristic. 

Method  of  Examination. — In  order  to  practise  it  most  easily  the 
patient  is  placed  on  a  couch  or  bed  in  a  position  midway  between  sit- 
ting and  lying,  by  which  the  vertical  diameter  of  the  uterine  cavity  is 
brought  into  correspondence  with  that  of  the  pelvis.  Two  fingers  of 
the  right  hand  are  then  passed  high  up  into  the  vagina  in  front  of  the 
cervix.  The  uterus  being  now  steadied  from  without  by  the  left  hand, 
the  intra-vaginal  fingers  press  the  uterine  wall  suddenly  upward,  when, 
if  pregnancy  exist,  the  foetus  is  displaced,  and  in  a  moment  falls  back 
again,  imparting  a  distinct  impulse  to  the  fingers.  When  easily  appre- 
ciable it  may  be  considered  as  a  certain  sign,  for  although  an  anteflexed 
fundus  or  a  calculus  in  the  bladder  may  give  rise  to  somewhat  similar 
sensations,  the  absence  of  other  indications  of  pregnancy  would  readily 
prevent  error.  Ballottement  js  practised  between  the  fourth,  and  seventh 
months.  Before  the  former  time  the  foetus  is  too  small,  while  at  a  later 
period  it  is  relatively  too  large,  and  can  no  longer  be  easily  made  to  rise 
upward  in  the  surrounding  liquor  amnii.  The  absence  of  ballottement 
must  not  be  taken  as  proving  the  non-existence  of  pregnancy,  for  it  may 
be  inappreciable  from  a  variety  of  causes,  such  as  abnormal  presentations 
or  the  implantation  of  the  placenta  upon  the  cervix  uteri. 

Vaginal  Pulsation. — There  are  also  some  other  vaginal  signs  of  preg- 
nancy of  secondary  consequence.  Amongst  these  is  the  vaginal  pulsa-  1 
tion  pointed  out  by  Osiander,  resulting  from  the  enlargement  of  the- 
vaginal  arteries,  which  may  sometimes  be  felt  beating  at  an  early  period. 
Often  this  pulsation  is  very  distinct,  at  other  times  it  cannot  be  felt  at 
all,  and  it  is  altogether  unreliable,  as  a  similar  pulsation  may  be  felt  in 
various  uterine  diseases. 

Uterine  Fluctuation. — Dr.  Rasch  has  drawn  attention  to  a  previously 
undescribed  sign  which  he  believes  to  be  of  importance  in  the  diagnosis 
of  early  pregnancy.^  It  consists  in  the  detection  of  fluctuation  through 
the  anterior  uterine  wall,  depending  on  the  presence  of  the  liquor  amnii. 
In  order  to  make  this  out,  tAvo  fingers  of  the  right  hand  must  be  used, 
'  Brit.  Med.  Journ.,  vol.  ii.,  1873. 


152  PREGNANCY. 

as  in  ballottement,  while  the  uterus  is  steadied  through  the  abdomen. 
Dr.  Rasch  states  that  by  this  means  the  enlarged  uterus  in  pregnancy 
can  easily  be  distinguished  from  the  enlargement  depending  on  other 
causes,  and  that  iluctuation  can  always  be  felt  as  early  as  the  second 
];nfiiiih.  If  it  is  associated  with  suppressed  menstruation  and  darkened 
areolae,  he  considers  it  a  certain  sign.  In  order  to  detect  it,  however, 
considerable  experience  in  making  vaginal  examinations  is  essential,  and 
it  can  hardly  be  depended  on  for  general  use. 

Alteration  in  Color  of  the  Vagina. — A  peculiar  deep  violet  liue  of  the 
vaginal  mucous  membrane  was  relied  on  by  Jacquemier  and  Kliige  as 
affording  a  readily  observed  indication  of  pregnancy.  In  most  cases  it 
is  well  marked  ;  sometimes,  indeed,  the  change  of  color  is  very  intense, 
and  it  evidently  depends  on  the  congestion  produced  by  pressure  of  the 
enlarged  uterus.  The  same  eifect,  however,  is  constantly  seen  where 
similar  pressure  is  effected  by  large  fibroid  tumors  of  the  uterus,  and, 
therefore,  for  diagnostic  purposes  it  is  valueless. 

Auscultatory  Signs  of  Pregnancy. — By  far  the  most  important  signs 
are  those  which  can  be  detected  by  abdominal  auscultation,  and  one  of 
these — the  hearing  of  the  fcetal  heart-sounds — forms  the  only  sign 
which  per  se,  and  in  the  absence  of  all  others,  is  perfectly  reliable. 

Discovery  of  Foetal  Auscultation. — The  fact  that  the  sounds  of  the  foetal 
heart  are  audible  during  advanced  pregnancy  was  first  pointed  out  by 
Mayor  of  Geneva  in  1818,  and  the  main  facts  in  connection  with  foetal 
auscultation  were  subsequently  worked  out  by  Kergaradec,  Xaegele, 
Evory  Kennedy,  and  other  observers.  The  pulsations  first  become 
audible,  as  a  rule,  in  the  course  of  the  fifth  month  or  about  the  middle 
of  the  fourth  month.  In  exceptional  circumstances  and  by  practised 
observers  they  have  been  heard  earlier.  Depaul  believes  that  he  de- 
tected them  as  early  as  the  eleventh  Aveek,  and  Routh  has  also  detected 
them  at  an  earlier  period  by  vaginal  stethoscopy,  which,  however,  for 
obvious  reasons,  cannot  be  ordinarily  employed.  Naegele  never  heard 
them  before  the  eighteenth  week,  more  generally  at  the  end  of  the  twen- 
tieth, and  for  practical  purposes  the  pregnancy  must  be  advanced  to  the 
fifth  month  before  we  can  reasonably  expect  to  detect  them.  From  this 
period  up  to  term  they  can  almost  always  be  heard — if  not  at  the  first 
attempt,  at  least  afterward,  to  a  certainty,  if  we  have  the  opportunity  of 
making  repeated  examinations.  Accidental  circumstances,  such  as  the 
presence  of  an  unusual  amount  of  flatus  in  the  intestines,  may  deaden 
the  sounds  for  a  time,  but  not  permanently.  Depaul  only  failed  to  hear 
them  in  8  cases  out  of  906  examined  during  the  last  three  months  of 
pregnancy ;  and  out  of  180  cases  which  Dr.  Anderson  of  Glasgow  care- 
fully examined,  he  only  failed  in  12,  and  in  each  of  these  the  child  was 
stillborn.  They  therefore  form  not  only  a  mast  certain  indication  of 
pregnancy,  but  of  the  life  of  the  foetus  also. 

Description  of  the  Sound. — The  sound  has  always  been  likened  to  the 
double  tic-tac  of  a  watch  heard  through  a  pillow,  which  it  closely 
resembles.  It  consists  of  two  beats,  separated  by  a  short  interval,  the 
first  being  the  loudest  and  most  distinct,  the  second  being  sometimes 
inaudible.  The  rapidity  of  the  foetal  pulsations  forms  an  important 
means  of  distinguishing  them  from  transmitted  maternal  pulsations,  with 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  153 

which  they  might  be  confounded.     Their  average  number  is  stated  by  I 
Slater,  who  made  numerous  observations  on  this  point,  to  be  132,  but  | 
sometimes  they  reach  as  high  as  140,  and  sometimes  as  low  as  120.     It  I 
will  thus  be  seen  that  the  pulsations  are  always  much  more  rapid  than 
those  of  the  mother's  heart,  unless,  indeed,  the  latter  be  unduly  acceler- 
ated by  transient  mental  emotion  or  disease.     To  avoid  mistakes,  when- 
ever the  foetal  heart  is  heard  its  rate  of  pulsation  should  be  carefully 
counted  and  compared  with  that  of  the  mother's  pulse ;   if  the  rate 
differ,  we  may  be  sure  that  no  error  has  been  made.     The  rapidity  of 
the  foetal  pulsations  remains,  as  a  rule,  the  same  during  the  whole 
period  of  pregnancy,  while  their  intensity  gradually  increases.     They 
may,  however,  be  temporarily  increased  or  diminished  in  frequency  by 
disturbing  causes,  such  as  the  pressure  of  the  stethoscope,  which,  excit- 
ing tumultuous  movements  of  the  foetus,  may  induce  greatly  increased 
frequency  of  its  heart-beats.     So  also  during  labor,  after  the  escape  of 
the  liquor  amnii,  when  the  contractions  of  the  uterus  have  a  very  dis- 
tinct influence  on  the  foetus,  they  may  be  greatly  modified.     An  acceler- 
ation or  irregularity  of  the  pulsations,  made  out  in  the  course  of  a  pro- 
longed labor,  may  thus  be  of  great  practical  importance,  by  indicating 
the  necessity  for  prompt  interference.    Similar  alterations,  associated  with  ! 
tumultuous  and  unusual  foetal  movements  felt  by  the  mother  toward ' 
the  end  of  pregnancy,  may  point  to  danger  to  the  life  of  the  foetus 
during  the  latter  months,  and  may  even  justify  the  induction  of  prema- 
ture labor.     This  is  especially  the  case  in  women  who  have  previously- 
given  birth  to  a  succession  of  dead  children  owing  to  disease  of  the  pla- 
centa, and  in  them  careful  and  frequently-repeated  auscultations  may 
warn  us  of  the  impending  danger. 

Supposed  Difference  of  Rapidity  according  to  the  Sex  of  the  Foetus. — 
The  rapidity  of  the  foetal  heart  has  been  supposed  by  some  to  afford  a 
means  of  determining  the  sex  of  the  child  before  birth.  Frankenhauser, 
who  first  directed  attention  to  this  point,  is  of  opinion  that  the  average 
rate  of  pulsations  of  the  heart  is  considerably  less  in  male  than  in  female 
children,  averaging  124  in  the  minute  in  the  former  as  against  144  in 
the  latter.  Steinbach  makes  the  difference  somewhat  less — viz.  131  for 
males  and  138  for  females.  He  predicted  the  sex  correctly  by  this 
means  in  45  out  of  57  cases,  while  Frankenhauser  was  correct  in  the 
whole  50  cases  which  he  specially  examined  with  reference  to  the  point. 
Dr.  Hutton  of  New  York^  was  also  correct  in  7  cases  he  fixed  on  for 
trial.  Devilliers  found  the  difference  in  the  sexes  to  be  the  same  as 
Steinbach  ;  he  attributes  it,  however,  to  the  size  and  weight  rather  than 
to  the  sex  of  the  child,  and  believes  the  pulsations  to'  be  least  numerous 
in  large  and  well-developed  children.  As  male  children  are  usually 
larger  than  female,  he  thus  explains  the  relatively  less  frequent  pulsa- 
tions of  their  hearts.  Dr.  Gumming  of  Edinburgh  also  believes  that 
the  weight  of  the  child  has  considerable  influence  on  the  frequency  of 
its  cardiac  pulsations,  so  that  a  large  female  child  may  have  a  slower 
pulse  than  a  small  male.^  The  point,  however,  is  more  curious  than 
practical,  and  the  rapidity  of  the  pulsations  certainly  would  not  jus- 
tify any  positive  prediction  on  the  subject.     Circumstances  influencing 

^  New  York  Med.  Jonrn.,  July,  1872.  '  Kdin.  Med.  Journ.,  1875. 


154  PREGNANCY. 

tlie   maternal    circulation    seem   to   have    no  influence  on  that  of  the 
foetus. 

*SVfe  at  which  the,  bounds  are  Heard. — The  foetal  heart-sounds  are  gen- 
erally propagated  best  by  the  back  of  the  child,  and  are  therefore  most 
easily  audible  when  this  is  in  contact  with  the  anterior  wall  of  the 
uterus,  as  is  the  case  in  the  large  majority  of  pregnancies.  AVhen  the 
child  is  placed  in  the  dorso-posterior  position  the  sounds  have  to  trav- 
erse a  larger  amount  of  the  liquor  amnii,  and  are  further  modified  by 
the  interposition  of  the  foetal  limbs.  They  are,  therefore,  less  easily 
heard  in  such  cases,  but  even  in  them  they  can  almost  always  be  made 
out.  As  the  foetus  most  frequently  lies  with  the  occiput  over  the  brim 
of  the  pelvis,  and  the  back  of  the  child  toward  the  left  side  of  the 
mother,  the  heart-sounds  are  usually  most  distinctly  audible  at  a  point 
midway  between  the  umbilicus  and  the  left  anterior-superior  spine  of 
the  ilium.  In  the  next  most  common  position,  in  wdiich  the  back  of  the 
child  lies  to  the  right  lumbar  region  of  the  mother,  they  are  generally 
heard  at  a  corresponding  point  at  the  right  side,  but  in  this  case  they 
are  frequently  more  readily  made  out  in  the  right  flank,  being  then 
transmitted  through  the  thorax  of  the  child,  which  is  in  contact  with 
the  side  of  the  uterus.  In  breech  cases,  on  the  other  hand,  the  heart- 
sounds  are  generally  heard  most  distinctly  above  the  umbilicus,  and 
either  to  the  right  or  left,  according  to  the  side  toward  which  the  back 
of  the  child  is  placed.  It  will  thus  be  seen  that  the  place  at  which  the 
foetal  heart-sounds  are  heard  varies  with  the  position  of  the  foetus  ;  and 
this,  when  combined  with  the  information  derived  from  palpation, 
affords  a  ready  means  of  ascertaining  the  presentation  of  the  child 
before  labor.  The  sounds  are  only  audible  over  a  limited  space  about 
two  or  three  inches  in  diameter ;  therefore,  if  w-e  fail  to  detect  them  in 
one  place,  a  careful  exploration  of  the  Avhole  uterine  tumor  is  necessary 
before  w^e  are  satisfied  that  they  cannot  be  heard. 

i  Sources  of  Fallacy. — The  only  mistake  that  is  likely  to  be  made  is 
taking  the  maternal  pulsations,  transmitted  through  the  uterine  tumor, 
for  those  of  the  foetal  heart.  A  little  care  wdll  easily  prevent  this  error, 
and  the  frequency  of  the  mother's  pulse  should  always  be  ascertained 
before  counting  the  supposed  foetal  pulsations.  If  these  are  found  to  be 
120  or  more,  while  the  mother's  pulse  is  only  70  or  80,  no  mistake  is 
possible.  If  the  latter  is  abnormally  quickened,  greater  care  may  be 
necessary,  but  even  then  the  rate  of  pulsation  of  each  will  be  dissimilar. 
Braxton  Hicks ^  has  pointed  out  that  in  tedious  labor,  when  the  mus- 
cular powers  of  the  mother  are  exhausted,  the  muscular  subsurrus  may 
produce  a  sound  closely  resembling  the  foetal  pulsation  ;  but  error  from 
this  source  is  obviously  very  improbable. 

3Iode  of  Practising  Auscultation. — In  listening  for  the  foetal  heart- 
sound  the  patient  should  be  placed  on  her  back,  with  the  shoulders 
elevated  and  the  knees  flexed.  The  surface  of  the  abdomen  should  be 
uncovered  and  an  ordinary  stethoscope  employed,  the  end  of  which 
must  be  pressed  firmly  on  the  tumor,  so  as  to  depress  the  abdominal 
walls.  The  most  absolute  stillness  is  necessary,  as  it  is  often  far  from 
easy  to  hear  the  sounds.     Sometimes,  after  failing  with  the  ordinary 

^  Obst.  Ivans.,  vol.  xv. 


SIGNS  AND  SYMPTOMS  OF  PREGNANCY.  155 

stethoscope,  I  have  succeeded  with  the  bin-aural,  which  remarkably 
intensifies  them.[']  When  once  heard  they  are  most  easily  counted 
during  a  space  of  five  seconds,  as,  on  account  of  their  frequency,  it 
is  not  always  possible  to  follow  them  over  a  longer  period. 

Value  of  this  Sign  of  Pregnancy. — When  the  foetal  heart-sounds  are 
heard  distinctly,  pregnancy  may  be  absolutely  and  certainly  diagnosed. 
The  fact  that  we  do  not  hear  them  does  not,  however,  preclude  the  pos- 
sibility of  gestation,  for  the  foetus  may  be  dead  or  the  sounds  tempo- 
rarily inaudible. 

Umbilical  Souffle. — There  are  some  other  sounds  heard  in  auscultation 
which  are  of  very  secondary  diagnostic  value.  One  of  these  is  the 
so-called  umbilical  or  funic  souffle,  which  was  first  pointed  out  by  Evory 
Kennedy.  It  consists  of  a  single  blowing  murmur,  synchronous  with 
the  foetal  heart-sounds,  and  most  distinctly  heard  in  the  immediate 
vicinity  of  the  point  where  these  are  most  audible.  Most  authors 
believe  it  to  be  produced  by  pressure  on  the  cord,  either  when  it  is  placed 
between  a  hard  part  of  the  foetus  and  the  uterine  walls  or  is  twisted 
round  the  child's  neck.  Schroeder  and  Hecker  detected  it  in  14  or  15 
per  cent,  of  all  cases,  and  the  latter  believed  it  to  be  caused  by  flexure 
of  the  first  portion  of  the  cord  near  the  umbilicus.  For  practical  pur- 
poses it  is  quite  valueless,  and  need  only  be  mentioned  as  a  phenomenon 
which  an  experienced  auscultator  may  occasionally  detect. 

21ie  Uterine  Saiffle. — The  uterine  souffle  is  a  peculiar  single  whizzing 
murmur  which  is  almost  always  audible  on  auscultation.  It  varies  very 
remarkably  in  character  and  position.  Sometimes  it  is  a  gentle  blowing 
or  even  musical  murmur ;  at  others  it  is  loud,  harsh,  and  scraping  ;  some- 
times continuous,  sometimes  intermittent.  It  may  also  be  heard  at  any 
point  of  the  uterus,  but  most  frequently  low  down  and  to  one  or  other 
side ;  more  rarely  above  the  umbilicus  or  toward  the  fundus ;  and  it 
often  changes  its  position  so  as  to  be  heard  at  a  subsequent  auscultation 
at  a  point  where  it  was  previously  inaudible.  It  may  be  heard  over  a 
space  of  an  inch  or  two  only,  or  in  some  cases  over  the  whole  uterine 
tumor ;  or,  again,  it  may  sometimes  be  detected  simultaneously  over  two 
entire  distinct  portions  of  the  uterus.  It  is  generally  to  be  heard  earlier 
than  the  foetal  heart-sounds,  often  as  soon  as  the  uterus  rises  above  the 
brim  of  the  pelvis,  and  it  can  almost  always  be  detected  after  the  com- 
mencement of  the  fourth  month.  The  sound  becomes  curiously  modified 
l^y  the  uterine  contractions  during  labor,  becoming  louder  and  more 
intense  before  the  pain  comes  on,  disappearing  daring  its  acme,  and  again 
being  heard  as  it  goes  off.  Hicks  attributes  to  a  similar  cause — viz.  the 
uterine  contractions  during  pregnancy — the  frequent  variations  in  the 
sound  which  are  characteristic  of  it.^  The  uterine  souffle  is  also  audible 
after  the  death  of  the  fretus,  and  it  is  believed  by  some  to  be  modified 
and  to  become  more  continuously  harsh  when  that  event  has  taken  place. 

Theories  as  to  its  Cause. — Very  various  explanations  have  been  given 

P  This  instrument  was  the  invention  of  the  late  Dr.  G.  P.  Cammann  of  New  York, 
and  thirty  years  ago  was  known  as  the  Cammann  stethoscope.  Dr.  C.  was  an  expert 
in  physical  explorations  of  the  chest,  and  devoted  his  life  to  the  study  of  its  dis- 
eases.— P3d.] 

''  Op.  ciL,  p.  223. 


156  PREGNANCY. 

of  the  causes  of  this  sound.  For  long  it  was  supposed  to  be  formed  in 
the  vessels  of  the  placenta,  and  hence  the  name  "  placental  souffle  "  by 
which  it  is  often  talked  of;  or,  if  not  in  the  placenta,  in  the  uterine 
vessels  in  its  immediate  neighborhood.  The  non-placental  origin  of  the 
sound  is  sufficiently  demonstrated  by  the  fact  that  it  may  be  heard  for  a 
considerable  time  after  the  expulsion  of  the  placenta.  Some  have  sup- 
posed that  it  is  not  formed  in  the  uterus  at  all,  but  in  the  maternal  ves- 
sels, especially  the  aorta  and  the  iliac  arteries,  owing  to  the  pressure  to 
which  they  are  subjected  by  the  gravid  uterus.  The  extreme  irregular- 
ity of  the  sound,  its  occasional  disappearance,  and  its  variable  site,  seem 
to  be  conclusive  against  this  view.  The  theory  which  refers  the  sound 
to  the  uterine  vessels  is  that  which  has  received  most  adherents,  and 
which  best  meets  the  facts  of  the  case ;  but  it  is  by  no  means  easy,  or 
even  possible,  to  account  for  the  exact  mode  of  its  production  in  them. 
Each  of  the  explanations  which  have  been  given  is  open  to  some  objec- 
tion. It  is  far  from  unlikely  that  the  intermittent  contractions  of  the 
uterine  fibres,  which  are  known  to  occur  during  the  whole  course  of 
pregnancy,  may  have  much  to  do  with  it,  by  modifying,  at  intervals, 
the  rapidity  of  the  circulation  in  the  vessels.  Its  production  in  this 
manner  may  also  be  favored  by  the  chlorotic  state  of  the  blood,  to  which 
Cazeaux  and  Scanzoni  are  inclined  to  attribute  an  important  influence, 
likening  it  to  the  ansemic  murmur  so  frequently  heard  in  the  vessels  in 
weakly  women. 

Ih  Diagnostic  Value. — From  a  diagnostic  point  of  view  the  uterine 
souffle  is  of  very  secondary  importance,  because  a  similar  sound  is  very 
generally  audible  in  large  fibroid  tumors  of  the  uterus,  and  even  in  some 
few  ovarian  tumors ;  it  is  therefore  of  little  or  no  value  in  assisting  us 
to  decide  the  character  of  the  abdominal  enlargement.  The  supposed 
dependence  of  the  sound  on  the  placental  circulation  has  caused  its  site 
to  be  often  identified  with  that  of  the  placenta.  It  is,  however,  most 
fre«[uently  heard  at  the  lower  part  of  the  uterus,  while  the  placenta  is 
generally  attached  near  the  fundus,  so  that  its  position  cannot  be  taken 
as  any  safe  guide  in  determining  the  situation  of  that  organ. 

Sounds  p'oduced  by  the  Movements  of  the  Foetus. — Occasionally,  in 
practising  auscultation,  irregular  sounds  of  brief  duration  may  be  heard 
M'hich  are  not  susceptible  of  accurate  description,  and  which  doubtless 
depend  on  the  sudden  movement  of  the  foetus  in  the  liquor  amnii  or  on 
the  impact  of  its  limbs  on  the  uterine  walls.  When  heard  distinctly 
they  are  characteristic  of  pregnancy,  and  they  may  be  sometimes  heard 
when  the  other  sounds  cannot  be  detected.  They  are,  however,  so  irregu- 
lar, and  so  often  entirely  absent,  that  they  can  hardly  be  looked  upon  in 
any  other  light  than  as  occasional  phenomena. 

Sounds  referred  to  Decomposition  of  the  Liquor  Amnii  and  to  Sepa- 
ration of  the  Placenta. — Two  other  sounds  have  been  described  as  being 
sometimes  audible  which  may  be  mentioned  as  matters  of  interest,  but 
which  are  of  no  diagnostic  value.  One  is  a  rustling  sound,  said  by  Stoltz 
to  be  audible  in  cases  in  which  the  foetus  is  dead,  and  which  he  refers  to 
gaseous  decomposition  of  the  liquor  amnii ;  its  existence  is,  however, 
extremely  problematical.  The  other  is  a  sound  heard  after  the  birth  of 
the  child,  and  referred  by  Caillant  to  the  separation  of  the  placental 


DIFFERENTIAL  DIAGNOSIS  OF  PBEONANCY.  157 

adhesions.  He  describes  it  as  a  series  of  rapid,  short  scratching  sounds, 
similar  to  those  produced  by  drawing  the  nails  across  the  seat  of  a  horse- 
hair sofa.  Simpson '  admitted  the  existence  of  the  sound,  but  believed 
that  it  is  produced  by  the  mere  physical  crushing  of  the  placenta,  and 
artificially  imitated  it  out  of  the  body  by  forcing  the  placenta  through 
an  aperture  the  size  of  the  os  uteri. 

Relative  Value  of  the  Signs  and  Symptoms  of  Pregnancy. — It  will  be 
seen,  then,  that  although  there  are  numerous  signs  and  symptoms  accom- 
panying pregnancy,  many  of  them  are  unreliable  by  themselves,  and  apt 
to  mislead.  Those  which  may  be  confidently  depended  on  are  the  pul- 
sations of  the  foetal  heart,  which,  however,  fail  us  in  cases  of  dead  chil- 
dren ;  the  foetal  movements  when  distinctly  made  out ;  ballottement ; 
the  intermittent  contractions  of  the  uterus ;  and  to  these  we  may  safely 
add  the  presence  of  milk  in  the  breasts,  provided  we  have  to  do  with  a 
first  pregnancy. 

The  remainder  are  of  importance  in  leading  us  to  suspect  pregnancy, 
and  in  corroborating  and  strengthening  other  symptoms,  but  they  do  not, 
of  themselves,  justify  a  positive  diagnosis. 


CHAPTER   V. 


THE  DIFFEEENTIAL  DIAGNOSIS  OF  PEEGNANCY.  SPUEIOUS  PEEG- 
NANCY.  THE  DUEATION  OF  PEEGNANCY.  SIGNS  OF  EECENT 
PEEGNANCY. 

Importance  of  the  Subject. — The  differential  diagnosis  of  pregnancy 
has  of  late  years  assumed  much  importance  on  account  of  the  advance 
of  abdominal  surgery.  The  cases  are  so  numerous  in  which  even  the 
most  experienced  practitioners  have  fallen  into  error,  and  in  which  the 
abdomen  has  been  laid  open  in  ignorance  of  the  fact  that  pregnancy 
existed,  that  the  subject  becomes  one  of  the  greatest  consequence.  For- 
tunately, it  is  less  so  from  an  obstetrical  than  from  a  gynsecological  point 
of  view,  inasmuch  as  the  converse  error,  of  mistaking  some  other  condi- 
tion for  pregnancy,  is  of  far  less  consequence,  as  it  is  one  which  time 
will  always  rectify.  But  even  in  this  way  carelessness  may  lead  to  very 
serious  injury  to  the  character,  if  not  to  the  health,  of  the  patient;  and 
it  will  be  well  to  refer  briefly  to  some  of  the  conditions  most  liable  to  be 
mistaken  fjr  pregnancy,  and  to  the  mode  of  distinguishing  them. 

Adipose  enlargement  of  the  abdomen  may  obscure  the  diagnosis  by 
preventing  the  detection  of  the  uterus ;  and  if,  as  is  not  uncommon  with 
women  of  great  obesity,  it  is  associated  with  irregular  menstruation,  the 
incTcased  size  of  the  al)d()men  might  be  supposed  to  depend  on  preg- 
naiuy.  The  absence  of  con-oborative  signs,  such  as  auscultatory  phe- 
nouKina,  mammary  changes,  and  the  hardness  of  the  cervix  as  felt  per 
vagi  nam,  makes  it  easy  to  avoid  this  error. 

^Selected  Ohstei.  Works,  p.  151. 


158  PREGNANCY. 

Distension  of  the  Uterus  by  Retained  Menses,  Hydrometra,  etc. — Dis- 
tension of  the  uterus  by  retained  menstrual  fluid  or  watery  secretion  is 
an  occurrence  of  rarity  that  could  seldom  give  rise  to  error.  Still,  it 
occasionally  happens  that  the  uterus  becomes  enlarged  in  this  way,  some- 
times reaching  even  to  the  level  of  the  umbilicus,  and  that  the  physical 
character  of  the  tumor  is  not  unlike  that  of  the  gravid  uterus.  The  best 
safeguard  against  mistakes  will  be  the  previous  history  of  the  case,  which 
wnllalways  be  different  from  that  of  ordinary  pregnancy.  Retention  of 
the  menses  almost  always  occurs  from  some  physical  obstruction  to  the 
exit  of  the  fluid,  such  as  imperforate  hymen  ;  or  if  it  occur  in  w^omen 
w^ho  have  already  menstruated,  we  may  usually  trace  a  history  of  some 
cause,  such  as  inflammation  following  an  antecedent  labor,  which  has 
produced  occlusion  of  some  part  of  the  genital  tract.  The  existence  of 
a  pelvic  tumor  in  a  girl  who  has  never  menstruated  will  of  itself  give 
rise  to  suspicion,  as  pregnancy  under  such  circumstances  is  of  extreme 
rarity.  It  will  also  be  found  that  general  symptoms  have  existed  for  a 
period  of  time  considerably  longer  than  the  supposed  duration  of  preg- 
nancy, as  judged  of  by  the  size  of  the  tumor.  The  most  characteristic 
of  them  are  periodic  attacks  of  pain  due  to  the  addition,  at  each  monthly 
period,  to  the  quantity  of  retained  menstrual  fluid.  Whenever,  from  any 
of  these  reasons,  suspicion  of  the  true  character  of  the  case  has  arisen,  a 
careful  vaginal  examination  will  generally  clear  it  up.  In  most  cases 
the  obstruction  will  be  in  the  vagina,  and  is  at  once  detected,  the  vaginal 
canal  above  it,  as  felt  per  rectum,  being  greatly  distended  by  fluid ;  and 
we  may  also  find  the  bulging  and  imperforate  hymen  protruding  through 
the  vulva.  The  absence  of  mammary  changes  and  of  ballottement  will 
materially  aid  us  in  forming  a  diagnosis. 

Congestive  Hypertmphy  of  the  Uterus. — The  engorged  and  enlarged 
uterus,  frequently  met  with  in  women  suifering  from  uterine  disease, 
might  readily  be  mistaken  for  an  early  pregnancy  if  it  happened  to  be 
associated  with  amenorrhcea.  A  little  time  would,  of  course,  soon  clear 
up  the  point,  by  showing  that  progressive  increase  in  size,  as  in  preg- 
nancy, does  not  take  place.  This  mistake  could  only  be  made  at  an 
early  stage  of  pregnancy,  when  a  positive  diagnosis  is  never  possible. 
The"^  accompanying  symptoms — pain,  inability  to  walk,  and  tenderness 
of  the  uterus  on  pressure— would  prevent  such  an  error. 

Ascitic  Distension  of  the  Abdomen. — Ascites,  j^er  se,  could  hardly  be 
mistaken  for  pregnancy,  for  the  uniform  distension  and  evident  fluctua- 
tion, the  absence  of  any  definite  tumor,  the  site  of  resonance  on  per- 
cussion changing  in  accordance  wath  alteration  of  the  position  of  the 
woman,  and  the  unchanged  cervix  and  uterus,  should  be  sufficient  to 
clear  up  any  doubt.  Pregnancy  may,  however,  exist  with  ascites,  and 
this  combination  may  be  difficult  to  detect,  and  might  readily  be  mis- 
taken for  ovarian  disease  associated  with  ascites.  The  existence  of  mam- 
mary changes,  the  presence  of  the  softened  cervix,  ballottement,  and 
auscultation — provided  the  sounds  were  not  masked  by  the  surrounding 
fluid — would  afl'ord  the  best  means  of  diagnosing  such  a  case. 

Uterine  and  Ovarian  Tumors. — One  of  the  most  frequent  sources  of 
difficulty  is  the  differential  diagnosis  of  large  abdominal  tumors,  either 
fibroid  or  ovarian,  or  of  some  enlargements  due  to  malignant  disease  of 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  159 

the  peritoneum  or  abdominal  viscera.  The  most  experienced  have  been 
occasionally  deceived  under  such  circumstances.  As  a  rule,  the  presence 
of  menstruation  will  prevent  error,  as  this  generally  continues  in  ovarian 
disease,  while  in  fibroids  it  is  often  excessive.  The  character  of  the 
tumor — the  fluctuation  in  ovarian  disease,  the  hard  nodular  masses  in 
fibroid — and  the  history  of  the  case,  especially  the  length  of  time  the 
tumor  has  existed,  will  aid  in  diagnosis,  while  the  absence  of  cervical 
softening  and  of  auscultatory  phenomena  will  further  be  of  material 
value  in  forming  a  conclusion.  Some  of  the  most  difficult  cases  to  diag- 
nose are  those  in  which  pregnancy  complicates  ovarian  or  fibroid  disease. 
Then  the  tumor  may  more  or  less  completely  obscure  the  physical  signs 
of  pregnancy.  The  usual  shape  of  the  abdomen  will  generally  be 
altered  considerably,  and  we  may  be  able  to  distinguish  the  gravid 
uterus,  separated  from  the  ovarian  tumor  by  a  distinct  sulcus,  or  with 
the  fibroid  masses  cropping  out  from  its  surface.  Our  chief  reliance 
must  then  be  placed  in  the  alteration  of  the  cervix  and  in  the  auscul- 
tatory signs  of  pregnancy. 

SjMtiQUS^j:egiiancy. — The  condition  most  likely  to  give  rise  to  errors 
is  that  very  interesting  and  peculiar  state  known  as  spurious  pregnancy. 
In  this  most  of  the  usual  phenomena  of  pregnancy  are  so  strangely 
simulated  that  accurate  diagnosis  is  often  far  from  easy.  There  are 
hardly  any  of  the  more  apparent  symptoms  of  pregnancy  which  may 
not  be  present  in  marked  cases  of  this  kind.  The  abdomen  may  become 
prominent,  the  areolse  altered,  menstruation  arrested,  and  apparent  foetal 
motions  felt ;  and,  unless  suspicion  is  aroused  and  a  careful  physical 
examination  made,  both  the  patient  and  the  practitioner  may  easily  be 
deceived. 

Cases  in  which  Spurious  Pregnancy  occurs. — There  is  no  period  of  the 
childbearing  life  in  which  spurious  pregnancy  may  not  be  met  with  ;  but 
it  is  most  likely  to  occur  in  elderly  women  about  the  climacteric  period, 
when  it  is  generally  associated  with  ovarian  irritation  connected  with  the 
change  of  life ;  or  in  younger  women,  who  are  either  very  desirous  of 
finding  themselves  pregnant,  or  who,  being  unmarried,  have  subjected 
themselves  to  the  chance  of  being  so.  In  all  cases  the  mental  faculties 
have  much  to  do  with  its  production,  and  there  is  generally  either 
very  marked  hysteria  or  even  a  condition  closely  allied  to  insanity. 
Spurious  pregnancy  is  by  no  means  confined  to  the  human  race.  It  is 
well  known  to  occur  in  many  of  the  lower  animals.  Harvey  related 
instances  in  bitches,  either  after  unsuccessful  intercourse  or  in  connection 
with  their  being  in  heat,  even  when  no  intercourse  had  occurred.  In 
such  cases  the  abdomen  SAvelled  and  milk  appeared  in  the  mammje. 
Similar  phenomena  are  also  occasionally  met  with  in  the  cow.  In  these 
instances,  as  in  the  human  female,  there  is  probably  some  morbid  irrita- 
tion of  tlie  ovarian  system. 

Its  Signs  and  Symptoms. — The  physical  phenomena  are  often  very 
well  marked.  The  a])parent  enlargement  is  sometimes  very  great,  and 
it  seems  to  be  produced  by  a  projection  forward  of  the  abdominal  con- 
tents diu!  to  depression  of  the  diapliragin,  together  with  rigidity  of  the 
alidoniinal  muscles,  and  may  even  closely  simulate  the  uterine  tumor  on 
palpation.     After  the  climacteric  it  is  frequently  associated,  as  Gooch 


160  PREGNANCY. 

pointed  out,  with  an  undue  deposit  of  fat  in  the  abdominal  walls  and 
omentum,  so  that  there  may  be  even  some  dulness  on  percussion,  instead 
of  resonance  of  the  intestines.  The  foetal  movements  are  curiously  and 
exactly  simulated,  either  by  involuntary  contractions  of  the  abdominal 
walls  or  by  the  movement  of  flatus  in  the  intestines.  The  patient  also 
generally  fancies  that  she  suffers  from  the  usual  sympathetic  disorders 
of  pregnancy,  and  thus  her  account  of  her  symptoms  will  still  further 
tend  to  mislead. 

Somvtiiaea  followed  by  Spurious  Labor. — Not  only  may  the  supposed 
pregnancy  continue,  but  at  what  would  be  the  natural  term  of  delivery 
all  the  phenomena  of  labor  may  supervene.  Many  authentic  cases  are 
on  record  in  which  regular  pains  came  on,  and  continued  to  increase  in 
force  and  frequency  until  the  actual  condition  was  diagnosed.  Such 
mistakes,  however,  are  only  likely  to  happen  when  the  statements  of 
the  patient  have  been  received  without  further  inquiry.  When  once  an 
accurate  examination  has  been  made  error  is  no  longer  possible. 

Methods  of  Diagnosis. — We  shall  generally  find  that  some  of  the  phe- 
nomena of  pregnancy  are  absent.  Possibly  menstruation,  more  or  less 
irregular,  may  have  continued.  Exajnination  per  vaginam  will  at  once 
clear  up  the  case,  by  showing  that  the  uterus  is  not  enlarged  and  that  the 
cervix  is  unaltered.  It  may  then  be  very  difficult  to  convince  the  patient 
or  her  friends  that  her  symptoms  have  misled  her,  and  for  this  purpose 
the  inhalation  of  chloroform  is  of  great  value.  As  consciousness  is 
abolished,  the  semi-voluntary  projection  of  the  abdominal  muscles  is  pre- 
vented, the  large  ajjparent  tumor  vanishes,  and  the  bystanders  can  be 
readily  convinced  that  none  exists.  As  the  patient  recovers  the  tumor 
again  appears. 

Duration  of  Pregnanoy. — The  duration  of  pregnancy  in  the  human 
female  has  always  formed  a  fruitful  theme  for  discussion  amongst 
obstetricians.  The  reasons  Avhich  render  the  point  difficult  of  decision 
are  obvious.  As  the  large  majority  of  cases  occur  in  married  women, 
in  whom  intercourse  occurs  frequently,  there  is  no  means  of  know- 
ing the  precise  period  at  which  conception  took  place.  The  only 
datum  which  exists  for  the  calculation  of  the  probable  date  of 
delivery  is  the  cessation  of  menstruation.  It  is  quite  possible,  how- 
ever, and  indeed  probable,  that  conception  occurred,  in  a  considerable 
number  of  instances,  not  immediately  after  the  last  period,  but  immedi- 
ately before  the  proper  epoch  for  the  occurrence  of  the  next.  Hence, 
as  the  interval  between  the  end  of  one  menstruation  and  the 
commencement  of  the  next  averages  25  days,  an  error  to  that  extent  is 
always  possible.  Another  source  of  fallacy  is  the  fact,  which  has  gen- 
erally been  overlooked,  that  even  a  single  coitus  does  not  fix  the  date  of 
conception,  but  only  that  of  insemination.  It  is  well  known  that  in 
many  of  the  lower  animals  the  fertilization  of  the  ovule  does  not  take 
place  until  several  days  after  copulation,  the  spermatozoa  remaining  in 
the  interval  in  a  state  of  active  vitality  within  the  genital  tract.  It  has 
been  shown  by  Marion  Sims  that  living  spermatozoa  exist  in  the  cervical 
canal  in  the  human  female  some  days  after  intercourse. ,  It  is  very  prob- 
able, therefore,  that  in  the  human  female,  as  in  the  lower  animals,  a  con- 
siderable but  unknown  interval  occurs  between  insemination  and  actual 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  161 

impregnation,  which  may  render  calculations  as  to  the  precise  duration 
of  pregnancy  altogether  unreliable. 

Average  Time  between  Cessation  of  Ifenstruation  and  Delivery. — A 
large  mass  of  statistical  observations  exists  respecting  the  average  duration 
of  gestation  which  has  been  drawn  up  and  collated  from  numerous 
sources.  It  would  serve  no  practical  purpose  to  reprint  the  voluminous 
tables  on  this  subject  that  are  contained  in  obstetrical  works.  They  are 
based  on  two  principal  methods  of  calculation.  First,  we  have  the 
length  of  time  between  the  cessation  of  menstruation  and  delivery.  This 
is  found  to  vary  very  considerably,  but  the  largest  percentage  of  deliveries 
occurs  between  the  274th  and  280th  day  after  the  cessation  of  menstru- 
ation, the  average  dayTjeing  the  278th  ;  but  in  individual  instances  very 
considerable  variations  both  above  and  below  these  limits  are  found  to 
exist.  Next  we  have  a  series  of  cases,  from  various  sources,  in  which 
only  one  coitus  was  believed  to  have  taken  place.  These  are  naturally 
always  open  to  some  doubt,  but,  on  the  whole,  they  may  be  taken  as 
affording  tolerably  fair  grounds  for  calculation.  Here,  as  in  the  other 
mode  of  calculation,  there  are  marked  variations,  the  average  length  of 
time,  as  estimated  from  a  considerable  collection  of  cases,  being  275  days 
after  the  single  intercourse.  It  may  therefore  be  taken  as  certain  that 
there  is  no  definite  time  which  we  can  calculate  on  as  being  the  proper 
duration  of  pregnancy,  and  consequently  no  method  of  estimating  the 
probable  date  of  delivery  on  which  we  can  absolutely  rely. 

Methods  of  Predicting  the  Probable  Date. — The  prediction  of  the  time 
at  which  the  confinement  may  be  expected  is,  however,  a  point  of  con- 
siderable practical  importance,  and  one  on  which  the  medical  attendant 
is  always  consulted.  Various  methods  of  making  the  calculation  have 
been  recommended.  It  has  been  customary  in  this  country,  according 
to  the  recommendation  of  Montgomery,  to  fix  upon  ten  lunar  months,  or 
280  days,  as  the  probable  period  of  gestation,  and,  as  conception  is  sup- 
posed to  occur  shortly  after  the  cessation  of  menstruation,  to  add  this 
number  of  days  to  any  day  within  the  first  week  after  the  last  menstrual 
period  as  the  most  probable  period  of  deliv^ery.  As,  however,  278  days 
are  found  to  be  the  average  duration  of  gestation  after  the  cessation  of 
menstruation,  and  as  this  method  makes  the  calculation  vary  from  281 
to  287  days,  it  is  evidently  liable  to  fix  too  late  a  date.  Naegele's  method 
was  to  count  seven  clays  from  the  first  appearance  of  the  last  menstrual 
period,  and  then  reckon  backward  three  months  as  the  probable  date. 
Thus,  if  a  patient  last  commenced  to  menstruate  on  August  10,  counting 
in  this  way  from  August  17  would  give  May  17  as  the  probable  date  of 
delivery. 

Matthews  Duncan  has  paid  more  attention  than  any  one  else  to  the 
predication  of  the  date  of  delivery.  His  method  of  calculating  is  based 
fm  the  fact  of  278  days  being  the  average  time  between  the  cessation  of 
menstruation  and  parturition  ;  and  he  claims  to  have  had  a  greater  aver- 
age; of  success  in  his  predictions  than  on  any  other  plan.  His  rule  is  as 
follows:  "Find  the  day  on  Avhich  the  female  ceased  to  menstruate,  or 
the  first  day  of  being  what  she  calls  'well.'  Take  that  day  nine  months 
forward  as  275,  unless  February  is  included,  in  which  case  it  is  taken  as 
27.3  (lays.  To  this  add  three  days  in  the  former  case,  or  five  if  February 
11 


162 


PREGNANCY. 


is  in  the  count,  to  make  up  the  278.  This  278th  day  should  then  be 
fixed  on  as  the  middle  of  the  week,  or,  to  make  the  prediction  the 
more  accurate,  of  the  fortnight,  in  which  the  confinement  is  likely  to 
occur,  by  which  means  allowance  is  made  for  the  average  variation  of 
either  excess  or  deficiency." 

Various  periodoscopes  and  tables  for  facilitating  the  calculation  have 
been  made.  The  periodoscope  of  Dr.  Tyler  Smith  (sold  by  Messrs.  John 
Smith  &  Co.,  52  Long  Acre)  is  very  useful  for  reference  in  the  consult- 
ing-foom,  giving  at  a  glance  a  variety  of  information,  such  as  the  prob- 
able period  of  quickening,  the  dates  for  the  induction  of  premature  labor, 
etc.  The  following  table,  prepared  by  Dr.  Protheroe  Smith,  is  also 
easily  read,  and  is  very  serviceable : 

Table  fob  Calculating  the  Period  of  Utero-Gestation.^ 


Nine  Calendar  Months. 

Ten  Lunar  Months. 

From 

To 

Days. 
273 

To 

Days. 

January 

Septembei 

30 

October 

7 

280 

February 

October 

31 

273 

November 

7 

280 

March 

November 

30 

275 

December 

5 

280 

April 

December 

31 

275 

Januarv 

5 

280 

May 

Januarv 

31 

276 

February 

4 

280 

June 

February 

28 

273 

March 

7 

280 

July 

March 

31 

274 

April 

6 

280 

A  ugust 

April 

30 

273 

May 

7 

280 

September 

May 

31 

273 

June 

7 

280 

October 

June 

30 

273 

July 

7 

280 

November 

July 

31 

273 

August 

7 

280 

December 

August 

31 

274 

September 

6 

280 

Quickening  a  Fallacious  Guide  in  estimating  Date  of  Delivery. — The 
date  at  which  the  quickening  has  been  perceived  is  relied  on  by  many 
practitioners,  and  still  more  by  patients,  in  calculating  the  probable  date 
of  delivery,  as  it  is  generally  supposed  to  occur  at  the  middle  of  preg- 
nancy. The  great  variations,  however,  at  the  time  at  which  this  phe- 
nomenon is  first  perceived,  and  the  difficulty  which  is  so  often  experienced 
of  ascertaining  its  presence  with  any  certainty,  render  it  a  very  fallacious 
guide.  The  only  times  at  which  the  perception  of  quickening  is  likely 
to  prove  of  any  real  value  are  when  impregnation  has  occurred  during 
lactation  (when  menstruation  is  normally  absent),  or  when  menstruation 
is  so  uncertain  and  irregular  that  the  date  of  its  last  appearance  cannot 
be  avScertained.  As  quickening  is  most  commonly  felt  during  the  fourth 
month — more  frequently  in  its  first  than  in  its  last  fortnight — it  may 
thus  afford  the  only  guide  we  can  obtain,  and  that  an  uncertain  one,  for 
predicting  the  date  of  delivery. 

I^  Protraction  of  Gestation  Possible  f — From  a  medico-legal  point  of 

^  Tlie  above  obstetric  "Ready  Reckoner"  consists  of  two  columns,  one  of  calendar, 
the  otlier  of  lunar,  months,  and  may  be  read  as  follows:  A  patient  h;is  censed  to  men- 
struate on  July  1:  her  confinement  may  be  expected  at  soonest  about  Marcli  31  [tlie 
end  of  vine  calendar  mnnihs),  or  at  latest  on  April  6  (llie  end.  of  ten  lunar  months). 
Another  has  ceased  to  menstruate  on  January  20:  her  confinement  maybe  expected 
on  September  30,  plus  20  days  {the  end.  of  nine  calendar  months),  at  soonest,  or  on 
October  7,  plus  20  days  {the  end  of  ten  lunar  m,onlhs),  at  latest. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  163 

view  the  question  of  the  possible  protraction  of  pregnancy  beyond  the 
average  time,  and  of  the  limits  within  which  such  protraction  can  be 
admitted,  is  of  very  great  importance.  The  law  on  this  point  varies 
considerably  in  different  countries.  Thus,  in  France  it  is  laid  down  that 
legitimacy  cannot  be  contested  until  300  days  have  elapsed  from  the 
death  of  the  husband  or  the  latest  possible  opportunity  for  sexual  inter- 
course. This  limit  is  also  adopted  by  Austria,  while  in  Prussia  it  is 
fixed  at  302  days.  In  England  and  America  no  fixed  date  is  admitted, 
but  while  280  days  is  admitted  as  the  "legitimum  terapus  pariendi," 
each  case  in  which  legitimacy  is  questioned  is  to  be  decided  on  its  own 
merij;s.  At  the  early  part  of  the  century  the  question  was  much  discussed 
by  the  leading  obstetricians  in  connection  with  the  celebrated  Gardner 
peerage  case,  and  a  considerable  difference  of  opinion  existed  among  them. 
Since  that  time  many  apparently  perfectly  reliable  cases  have  been  re- 
corded in  which  the  duration  of  gestation  was  obviously  much  beyond 
the  average,  and  in  which  all  sources  of  fallacy  were  carefully  excluded. 

Reliable  Cases  of  Protraction. — Not  to  burden  these  pages  with  a 
number  of  cases,  it  may  suffice  to  refer,  as  examples  of  protraction,  to 
four  well-known  instances  recorded  by  Simpson,^  in  which  the  preg- 
nancy extended  respectively  to  336,  332,  319,  and  324  days  after  the 
cessation  of  the  last  menstrual  period.  In  these,  as  in  all  cases  of  pro- 
tracted gestation,  there  is  the  possible  source  of  error  that  impregnation 
may  have  occurred  just  before  the  expected  advent  of  the  next  period. 
Making  an  allowance  of  23  days  in  each  instance  for  this,  we  even  then 
have  a  number  of  days  much  above  the  average — viz.  313,  309,  296, 
and  301.  Numerous  instances  as  Curious  may  be  found  scattered  through 
obstetric  literature.  Indeed,  the  experience  of  most  accoucheurs  will 
parallel  such  cases,  which  may  be  more  common  than  is  generally  sup- 
posed, inasmuch  as  they  are  only  likely  to  attract  attention  when  the 
husband  has  been  separated  from  the  wife  beyond  the  average  and 
expected  duration  of  the  pregnancy. 

Protraction  Common  in  the  Loiver  Animals. — The  evidence  in  favor 
of  the  possible  prolongation  of  gestation  is  greatly  strengthened  by  what 
is  known  to  occur  in  the  lower  animals.  In  some  of  these,  as  in  the 
cow  and  the  mare,  the  precise  period  of  insemination  is  known  to  a 
certainty,  as  only  a  single  coitus  is  permitted.  Many  tables  of  this 
kind  have  been  constructed,  and  it  has  been  shown  that  there  is  in  them 
a  very  considerable  variation.  In  some  cases  in  the  cow  it  has  been 
found  that  delivery  took  place  45  days,  and  in  the  mare  43  days,  after 
the  calculated  date.  Analogy  would  go  strongly  to  show  that  what  is 
known  to  a  certainty  to  occur  in  the  lower  animals  may  also  take  place 
in  the  human  female.  The  fact,  indeed,  is  now  very  generally  admitted  ; 
Ijiit  we  are  still  unable  to  fix  with  any  degree  of  precision  on  the  extreme 
limit  to  \vhi(,'h  protraction  is  possible.  Some  practitioners  have  given 
cases  in  wlii(;li,  on  data  which  they  believe  to  be  satisfactory,  pregnancy 
has  been  extremely  protracted  ;  thus,  Meigs  and  Adler  record  instances 
which  they  believed  to  have  been  ])rolonged  to  over  a  year  in  one  case 
and  over  fourteen  months  in  the  other.  These  are,  however,  so  prob- 
lematical that  little  weight  can  be  attached  to  them.     On  the  whole,  it 

*  Obstet.  MemoirH,  p.  84. 


164  PREGNANCY. 

would  hardly  be  safe  to  conclude  that  pregnancy  can  go  more  than  three 
or  four  weeks  beyond  the  average  time.  This  conclusion  is  justified  by 
the  cases  we  possess  in  which  pregnancy  followed  a  single  coitus,  the 
longest  of  which  was  295  days. 

Evidence  from  Size  of  Child. — Dr.  Duncan^  is  inclined  to  refuse 
credence  to  every  case  of  supposed  protraction  unless  the  size  and 
weight  of  the  child  are  above  the  average,  believing  that  lengthened 
gestation  must  of  necessity  cause  increased  growth  of  the  child.  This 
point  requires  further  investigation,  and  it  cannot  be  taken  as  proved 
that  the  foetus  necessarily  must  be  large  because  it  has  been  retained 
longer  than  usual  in  utero ;  or,  even  if  this  be  admitted,  it  may  have 
been  originally  small,  and  so  at  the  end  of  the  protracted  gestation  be 
little  above  the  average  weight.  There  are,  how^ever,  many  cases  which 
certainly  prove  that  a  prolonged  pregnancy  is  at  least  often  associated 
with  an  unusually-developed  foetus.  Dr.  Duncan  himself  cites  several, 
and  a  very  interesting  one  is  mentioned  by  Leishman  in  which  delivery- 
took  place  295  days  after  a  single  coitus,  the  child  weighing  12  lbs.  3  oz. 

In  some  cases  Labor  may  Commence  and  be  AiTested. — It  seems 
possible  that,  in  some  cases  of  protracted  pregnancy,  labor  actually 
came  on  at  the  average  time,  but,  on  account  of  faulty  positions  of  the 
uterus  or  other  obstructing  cause,  the  pains  were  ineffective  and  ulti- 
mately died  away,  not  recurring  for  a  considerable  time.  Joulin  relates 
some  instances  of  this  kind.  In  one  of  them  the  labor  was  expected 
from  the  20th  to  the  25th  of  October.  He  was  summoned  on  the  23d, 
and  found  the  pains  regular  and  active,  but  ineffective ;  after  lasting  the 
whole  of  the  24th  and  25th  they  died  away,  and  delivery  did  not  take 
place  until  November  25th,  after  the  laj)se  of  a  month.  In  this  instance 
the  apparent  cause  of  difficulty  was  extreme  anterior  obliquity  of  the 
uterus.  A  precisely  similar  case  came  under  my  own  observation.  The 
lady  ceased  to  menstruate  on  March  16,  1870.  On  December  12th — 
that  is,  on  the  273d  day — strong  labor-pains  came  on,  the  os  dilated  to 
the  size  of  a  florin,  and  the  membranes  became  tense  and  prominent 
with  each  pain.  After  lasting  all  night  they  gradually  died  away,  and 
did  not  recur  until  January  12th,  304  clays  from  the  cessation  of  the 
last  period.  Here  there  was  no  assignable  cause  of  obstruction,  and  the 
labor,  when  it  did  come  on,  was  natural  and  easy. 

The  curious  fact  that  in  both  these  cases,  as  in  others  of  the  same 
kind  that  are  recorded,  labor  came  on  exactly  a  month  after  the  previous 
ineffectual  attempt  at  its  establishment,  affords,  so  far  as  it  goes,  an 
argument  in  favor  of  the  view  maintained  by  many  that  labor  is  apt  to 
come  on  at  what  would  have  been  a  menstrual  period. 

Signs  of  Recent  Delivery. — From  a  forensic  point  of  view  it  often 
becomes  of  importance  to  be  able  to  give  a  reliable  opinion  as  to  the 
fact  of  delivery  having  occurred,  and  a  few  words  may  be  here  said  as 
to  the  signs  of  recent  delivery.  Our  opinion  is  only  likely  to  be  sought 
in  cases  in  which  the  fact  of  delivery  is  denied,  and  in  which  we  must, 
therefore,  entirely  rely  on  the  results  of  a  physical  examination.  If  this 
be  undertaken  within  the  first  fortnight  after  labor,  a  positive  conclusion 
can  be  readily  arrived  at. 

^  Fecundity  and  Fertility,  p.  348. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  165 

At  this  time  the  abdominal  walls  will  still  be  funnel  loose  and  flaccid, 
and  bearing  very  evident  marks  of  extreme  distension  in  the  cracks  and 
fissures  of  the  cutis  vera.  These  remain  permanent  for  the  rest  of  the 
patient's  life,  and  may  be  safely  assumed  to  be  signs  of  an  antecedent 
pregnancy,  provided  we  can  be  certain  that  no  other  cause  of  extreme 
abdominal  distension  has  existed,  such  as  ascites  or  ovarian  tumor. 

Within  the  first  few  days  after  delivery  the  hard  round  ball  formed 
by  the  contracted  and  empty  uterus  can  easily  be  felt  by  abdominal 
palpation,  and  more  certainly  by  combined  external  and  internal  exami- 
nation. The  process  of  involution,  however,  by  which  the  uterus  is 
reduced  to  its  normal  size,  is  so  rapid  that  after  the  first  week  it  can  no 
longer  be  made  out  above  the  brim  of  the  pelvis.  In  cases  in  which  an 
accurate  diagnosis  is  of  importance  the  increased  length  of  the  uterus 
can  be  ascertained  by  the  uterine  sound,  and  its  cavity  will  measure 
more  than  the  normal  2|-  inches  for  at  least  a  month  after  delivery. 
It  should  not  be  forgotten  that  the  uterine  parietes,  are  now  undergoing 
fatty  degeneration,  and  that  they  are  more  than  usually  soft  and  friable, 
so  that  the  sound  should  be  used  with  great  caution  and  only  when  a 
positive  opinion  is  essential.  The  state  of  the  cervix  and  of  the  vagina 
may  afford  useful  information.  Immediately  after  delivery  the  cervix 
hangs  loose  and  patulous  in  the  vagina,  but  it  rapidly  contracts,  and 
the  internal  os  is  generally  entirely  closed  after  the  eighth  or  tenth  day. 
The  remainder  of  the  cervix  is  longer  in  returning  to  its  normal  shape 
and  consistency.  It  is  generally  permanently  altered  after  delivery,  the 
external  os  remaining  fissured  and  transverse,  instead  of  circular  with 
smooth  margins,  as  in  virgins.  The  vagina  is  at  first  lax,  swollen,  and 
dilated,  but  these  signs  rapidly  disappear,  and  cannot  be  satisfactorily 
made  out  after  the  first  few  days.  The  absence  of  the  fourchette  may 
be  recognized,  and  is  a  persistent  sign. 

The  presence  of  the  lochia  affords  a  valuable  sign  of  recent  delivery. 
For  the  first  i&w  clays  they  are  sanguineous,  and  contain  numerous 
blood-corpuscles,  epithelial  scales,  and  the  debris  of  the  decidua.  After 
the  fifth  day  they  generally  change  in  color  and  become  pale  and 
greenish,  and  from  the  eighth  or  ninth  day  till  about  a  month  after 
delivery  they  have  the  appearance  of  thick  opalescent  mucus.  They 
have,  however,  a  peculiar,  heavy,  sickening  odor,  which  should  prevent 
their  being  mistaken  for  either  menstruation  or  leucorrhoeal  discharge. 

The  appearance  of  the  breasts  will  also  aid  the  decision,  for  it  is 
impossible  for  the  patient  to  conceal  the  turgid,  swollen  condition  of  the 
mammae,  with  the  darkened  areolae,  and,  above  all,  the  presence  of  milk. 
If,  on  microscopic  examination,  the  milk  is  found  to  contain  colostrum- 
corpuscles,  the  fact  of  very  recent  delivery  is  certain.  In  women  who 
do  not  nurse  it  should  be  remembered  that  the  secretion  of  milk  often 
rapidly  disappears,  so  that  its  absence  cannot  be  taken  as  a  sign  that 
delivery  has  not  taken  place.  On  the  whole,  there  should  be  no 
difficulty  in  deciding  tliat  a  woman  has  been  delivered,  as  some  of  tlie 
signs  are  persistent  for  the  rest  of  her  life ;  but  it  is  not  so  easy,  unless 
we  see  the  case  within  the  first  eight  or  ten  days,  to  say  how  long  it  is 
since  labor  took  place. 


166 


PREGNANCY. 


CHAPTER    VI. 

ABNORMAL  PREGNANCY,  INCLUDING  MULTIPLE  PREGNANCY, 
SUPERFCETATION,  EXTRA-UTERINE  FCETATION,  AND  MISSED 
LABOR. 


Plural  Births  an  Abnormal  Variety  of  Pregnancy. — The  occurrence 
of  more  than  one  foetus  in  utero  is  far  from  uncommon,  but  there  are 
circumstances  connected  with  it  which  justify  the  conclusion  that  phiral 
births  must  not  be  classified  as  natural  forms  of  pregnancy.  The  rea- 
sons for  this  statement  have  been  well  collected  by  Dr.  Arthur  Mitchell/ 
who  conclusively  shows  that  not  only  is  there  a  direct  increase  of  risk 
both  to  the  mother  and  her  offspring,  but  that  many  abnormalities,  such 
as  idiocy,  imbecility,  and  bodily  deformity,  occur  with  much  greater 
frequency  in  twins  than  in  single-born  children.  He  concludes  that 
"the  whole  history  of  twin  births  is  excej)tional,  indicates  imperfect 
development  and  feeble  organization  in  the  product,  and  leads  us  to 
regard  twinning  in  the  human  species  as  a  departure  from  the  physio- 
logical rule,  and  therefore  injurious  to  all  concerned." 

Frequency  of  Multiple  Births. — The  frequency  of  multiple  births 
varies  considerably  under  different  circumstances.  Taking  the  average 
of  a  large  number  of  cases  collected  by  authors  in  various  countries,  we 
find  that  twin  pregnancies  occur  aboiit  once  in  87_labors  ;  triplets,  once 
in  7679.  A  certain  number  of  quadruple  pregnancies,  and  some  cases 
of  early  abortion  in  which  there  were  five  foetuses,  are  recorded,  so  that 
there  can  be  no  doubt  of  the  possibility  of  such  occurrences ;  but  they 
are  so  extremely  uncommon  that  they  may  be  looked  upon  as  rare 
exceptions,  the  relative  frequency  of  which  can  hardly  be  determined. 

The  frequency  of  multiple  pregnancy  varies  remarkably  in  different 
races  and  countries.     The  following  table ^  will  show  this  at  a  glance: 

Relative  Frequency  of  Multiple  Pregnancies  in  Europe. 


Countries. 


England 

Austria 

Grand  Duchy  of  Baden 

Scotland 

France  

Ireland 

Mecldenburg-Schwerin 

Norway 

Prussia 

Russia 

Saxony    ....... 

vSwitzerland 

Wiirtenibers; 


Proportion  of 

Twin  to  Single 

Births. 


1  :116 

1:94 

1:89 

1  :95 

1:99 

1:64 


68.9 

81.62 

89 

50.05 

79 

102 

862 


Proportion  of 
Triplets. 

1 

6,720 

1 

6,575 

1 
1 
1 
1 

1 
1 
1 

8,256 
4,995 
6,436 
5,442 
7,820 
4,054 
1,000 

1 

6,464 

Proportion  of 
Quadruplets. 


1  :  2,074,306 
1  :  167,226 
1 :     183,236 

1 :     394,690 

1 :     400,000 

1  :     110,991 


Med.  Times  and  Oaz.,  Nov.,  1862. 


^  Puech,  Des  Naissances  Multiples^. 


ABNORMAL  PREGNANCY.  167 

It  will  be  seen  that  the  largest  proportion  of  multiple  births  occurs  in 
Russia,  and  that  the  number  of  triple  births  is  greatest  where  twin  preg- 
nancies are  most  frequent.  Puech  concludes  that  the  number  of  multi- 
ple pregnancies  is  in  direct  proportion  to  the  general  fecundity  of  the 
inhabitants. 

Dr.  Duncan  has  deduced  some  interesting  laws  with  regard  to  the 
production  of  twins  from  a  large  number  of  statistical  observations;^ 
especially,  that  the  tendency  to  the  production  of  twins  increases  as  the 
age  of  the  woman  advances,  and  is  greater  in  each  succeeding  pregnancy, 
exception  being  made  for  the  first  pregnancy,  in  which  it  is  greater  than 
in  any  other.  Newly-married  women  appear  more  likely  to  have  twins 
the  older  they  are.  There  can  be  no  doubt  that  there  is  often  a  strong 
hereditary  tendency  in  individual  families  to  multiple  births.  A 
remarkable  instance  of  this  kind  is  recorded  by  Mr.  Curgenven,^  in 
which  a  woman  had  four  twin  pregnancies,  her  mother  and  aunt  each 
one,  and  her  grandmother  two.  Simpson  mentions  a  case  of  quad- 
ruplets, consisting  of  three  males  and  one  female,  who  all  survived,  the 
female  subsequently  giving  birth  to  triplets.^ 

Sex  of  Children. — In  the  largest  number  of  cases  of  twins  the  children 
are  of  opposite  sexes,  next  most  frequently  there  are  two  females,  and  | 
twin  males  are  the  most  uncommon.  Thus,  out  of  59,178  labors,- 
Simpson  calculates  that  twin  male  and  female  occurred  once  in  199 
labors,  twin  females  once  in  226,  and  twin  males  once  in  258.  The 
proportion  of  male  to  female  births  is  also  notably  less  in  twin  than  in 
single  pregnancies. 

Size  of  Foetuses. — Twins,  and,  a  fortiori,  triplets,  are  almost  always  ! 
smaller  and  less  perfectly  developed  than  single  children.  Hence  the  J 
chances  of  their  survival  are  much  less,  and  Clarke  calculates  the  mor- 
tality amongst  twin  children  as  one  out  of  thirteen.  Of  triplets,  indeed, 
it  is  comparatively  rare  that  all  survive ;  while  in  quadruplets  premature 
labor  and  the  death  of  the  foetuses  are  almost  certain.  It  is  a  common 
observation  that  twins  are  often  unequally  developed  at  birth.  By  some 
this  difference  is  attributed  to  one  of  them  being  of  a  different  age  to  the 
other.  It  is  probable,  however,  that  in  most  of  these  cases  the  full 
development  of  one  foetus  has  been  interfered  with  by  pressure  of  the 
otlier.  This  is  far  from  uncommonly  carried  to  the  extent  of  destroying 
one  of  the  twins,  which  is  expelled  at  term,  mummified  and  flattened 
between  the  living  child  and  the  uterine  wall.  In  other  cases,  when  one 
foetus  dies  it  may  be  expelled  without  terminating  the  pregnancy,  the 
other  being  retained  in  utero  and  born  at  term ;  and  those  who  dis- 
believe in  the  possibility  of  superfoetation  explain  in  this  way  the  cases 
in  which  it  is  l)Glieved  to  have  occurred. 

CavHPH. — Multiple  pregnancies  depend  on  various  causes.  The  most 
common  is  probably  the  sinuiltaneous,  or  nearly  sinuiltaneous,  matura- 
tion and  rupture  of  two  Graafian  follicles,  the  ovules  becoming  im[)reg- 
nated  at  or  about  the  same  time.  It  by  no  means  necessarily  follows, 
even  if  more  than  one  follicle  should  rupture  at  once,  that  both  ovules 
should  be  impregnated.     This  is  proved  by  the  occurrence  of  cases  in 

'  On  Fecundltii,  FcrlilUy,  and  Sterility,  p.  99.  ^  Obst.  Trans.,  vol  xi. 

^  Obsl.  Works',  p.  830. 


168  PREGNANCY. 

which  there  are  two  corpora  kitea  with  only  one  foetus.  There  are 
numerous  facts  to  prove  that  ovules  thrown  off  within  a  short  time  of 
each  other  may  become  sej^arately  impregnated,  as  in  cases  in  which 
negro  women  have  given  birth  to  twins,  one  of  which  was  pure  negro, 
the  other  half-caste. 

It  may  happen,  however,  that  a  single  Graafian  follicle  contains  more 
than  one  ovule,  as  has  actually  been  observed  before  its  rupture  ;•  or,  as 
is  not  uncommon  in  the  egg  of  the  fowl,  an  ovule  may  contain  a  double 
germ,  each  of  which  may  give  rise  to  a  separate  fcetus. 

Arrangement  of  the  Foetal  3Iembranes  and  Flacentce. — The  various 
modes  in  which  twins  may  originate  exjilain  satisfactorily  the  variations 
which  are  met  Avitli  in  the  arrangement  of  the  foetal  membranes  and  in 
the  form  and  connections  of  the  placentae.  In  a  large  proportion  of 
'  i  cases  there  are  two  distinct  bags  of  ^membranes,  the  septum  between 
them  being  composed  of  four  layers — viz.  the  chorion  and  amnion  of 
each  ovum.  The  placentae  are  also  entirely  separate.  Here  it  is  obvi- 
ous that  each  twin  is  developed  from  a  distinct  ovum,  having  its  own 
chorion  and  amnion.  On  arriving  in  the  uterus  it  is  probable  that  each 
ovum  becomes  fixed  independently  in  the  mucous  membrane  and  is  sur- 
rounded by  its  own  decidua  reflexa.  As  gro^^i:h  ad\'ances  the  decidua 
reflexa  generally  atrophies  from  pressure,  as  it  is  not  usual  to  find  more 
than  four  layers  of  membrane  in  the  septum  separating  the  ova.  In 
other  cases  there  is  only  one  chorion,  within  which  are  two  clislinct 
amnions,  the  septum  then  consisting  of  two  layers  only.  Then  the 
placentae  are  generally  in  close  apposition  and  become  fused  into  a  single 
mass,  the  cords,  separately  attached  to  each  foetus,  not  infrequently  unit- 
ing shortly  before  reaching  the  placental  mass,  their  vessels  anastomosing 
freely.  In  other  more  rare  instances  both  foetuses  are  contained  in  a 
common  amniotic  sac ;  but  as  the  amnion  is  a  purely  foetal  membrane, 
it  is  probable  that,  when  this  arrangement  is  met  with,  the  originally 
existing  septum  between  the  amniotic  sacs  has  been  destroyed.  In  both 
these  latter  cases  the  twins  must  have  been  developed  from  a  single 
ovule  containing  a  double  germ,  and  Schroeder  states  that  they  are  then 
always  of  the  same  sex.  Dr.  Brunton '  has  started  a  precisely  opposite 
theory,  and  has  tried  to  prove  that  twins  of  the  same  sex  are  contained 
in  separate  bags  of  membrane,  while  twins  of  opposite  sexes  have  a  com- 
mon sac.  He  says  that  out  of  25  cases  coming  under  his  observation, 
in  15  the  children  contained  in  different  sacs  were  of  the  same  sex,  but 
in  the  remaining  10,  in  which  there  was  only  one  sac,  they  were  of 
opposite  sexes.  It  is  difficult  to  believe  that  there  is  not  an  error  in 
these  observations,  since  twins  contained  in  a  single  amniotic  sac  do  not 
occur  nearly  as  often  as  ten  times  out  of  twenty-five  cases,  and  no  dis- 
tinction is  made  between  a  common  chorion  with  two  amnions  and  a 
single  chorion  and  amnion.  The  facts  of  double  monstrosity  also  dis- 
prove this  view,  since  conjoined  twins  must  of  necessity  arise  from  a 
single  ovule  with  a  double  germ,  and  there  is  no  instance  on  record  in 
which  they  were  of  opposite  sexes. 

Membranes  and  Placerdce  in  Triplets. — In  triplets  the  membranes  and 
placentae  may  be  all  separate,  or,  as  is  commonly  the  case,  there  is  one 

^  Obst.  'Trans.,  vol.  x. 


ABNORMAL  PREGNANCY.  169 

complete  bag  of  membranes,  and  a  second  having  a  common  chorion, 
with  a  double  amnion.     It  is  probable,  therefore,  that  triplets  are  gen-  ] 
erally  developed  from  two  ovules,  one  of  which  contained  a  double  germ.  ; 

Diagnosis  of  Midtiple  Pregnancy. — It  is  comparatively  seldom  that 
twin  pregnancy  can  be  diagnosed  before  the  birth  of  the  first  child,  and 
even  when  suspicion  has  arisen  its  indications  are  very  defective.  There 
is  generally  an  unusual  size  and  an  irregularity  of  shape  of  the  uterus, 
sometimes  even  a  distinct  depression  or  sulcus  between  the  two  foetuses. 
When  such  a  sulcus  exists,  it  may  be  possible  to  make  out  parts  of  each 
foetus  by  palpation  on  either  side  of  the  uterus.  The  only  sign,  how-  I 
ever,  on  which  the  least  reliance  can  be  placed  is  the  detection  of  two  \ 
foetal  hearts.  If  two  distinct  pulsations  are  heard  at  different  parts  of  ^ 
the  uterus  ;  if,  on  carrying  the  stethoscope  from  one  point  to  another, 
there  is  an  interspace  where  pulsations  are  no  longer  audible,  or  Avhen 
they  become  feeble  and  again  increase  in  clearness  as  the  second  point  is 
reached ;  and,  above  all,  if  we  are  able  to  make  out  a  difference  in  fre- 
quency between  them, — the  diagnosis  is  tolerably  safe.  It  must  be 
remembered,  however,  that  the  sounds  of  a  single  heart  may  be  heard 
over  a  larger  space  than  usual,  and  hence  a  possible  source  of  error. 
Twin  pregnancy,  moreover,  may  readily  exist  without  the  most  careful 
auscultation  enabling  us  to  detect  a  double  pulsation,  especially  if  one 
child  lie  in  the  dorso-posterior  position,  when  the  body  of  the  other  may 
prevent  the  transmission  of  its  heart's  beat.  The  so-called  placental 
souffle  is  generally  too  diffuse  and  irregular  to  be  of  any  use  in  diagnosis 
even  when  it  is  distinctly  heard  at  separate  parts  of  the  uterus. 

Superfoetation  and  Superfecundation. — Closely  connected  with  the  sub- 
ject of  multiple  pregnancies  are  the  conditions  known  as  superfecunda- 
tion and  siuperfoetation,  regarding  which  there  has  been  much  controversy 
and  difference  of  opinion. 

By  the  former  is  meant  the  fecundation,  at  or  near  the  same  period  of  | 
time,  of  two  separate  ovules  before  the  clecidua  lining  the  uterus  has  ( 
been  formed,  which  by  many  is  supposed  to  form  an  insuperable  obsta-  i, 
cle  to  subsequent  impregnation.     The  j^ossibility  of  this  occurrence  hasJ 
been  incontestably  proved  by  the  class  of  cases  already  referred  to,  in 
which  the  same  woman  has  given  birth  to  twins  bearing  evident  traces 
of  being  the  offspring  of  fathers  of  different  races. 

By  supeifoetation  is  meant  the  impregnation  of  a  second  ovule,  when  • 
the  uterus  already  contains  an  ovum  which  has  arrived  at  a  considerable 
degree  of  devehjpment.  The  cases  which  are  supposed  to  prove  the  pos-^ 
sibility  of  this  occurrence  are  very  numerous.  They  are  those  in  which 
a  woman  is  delivered  simultaneously  of  foetuses  of  very  different  ages, 
one  bearing  all  the  marks  of  having  arrived  at  term,  the  other  of  pre- 
maturity ;  or  of  tliose  in  which  a  woman  is  delivered  of  an  apparently 
mature  child,  and,  after  the  la]>se  of  a  few  months,  of  another  e(|ually 
mature.  The  j)()ssibi]ity  of  sup(!rfrjotation  is  strongly  denied  by  many 
practitioners  of  eminenc(f,  and  explanations  are  given  wliich  d()ul)tless 
seem  to  account  satisfactorily  for  a  large  proportion  of  the  su])posed 
examples.  In  the  former  class  of  cases  it  is  supposed,  with  much  proba- 
bility, that  there  is  an  ordinary  twin  pregnancy,  the  development  of  one 
ffjetus  b(!ing  retarded  by  the  presence  in  utero  of  another.     That  this  is 


170  PREGNANCY. 

not  an  uncommon  occurrence  is  certain,  and  the  fact  has  ah'eacly  been 
alkided  to  in  treating  of  twin  pregnancy.  In  cases  of  the  latter  kind  it 
is  possible  that  some  of  them  may  be  due  to  separate  impregnation  in  a 
i  bilobed  uterus,  the  contents  of  one  division  being  thrown  off  a  consider- 
able time  before  those  of  the  other.  Numerous  authentic  examples  of 
this  occurrence  are  recorded,  but  by  far  the  most  remarkable  is  that 
related  by  Dr.  Ross  of  Brighton,  Avhich  has  been  already  referred  to 
(p.  67).  In  this  case  the  patient  had  previously  given  birth  to  many 
children  without  any  suspicion  of  her  abnormal  formation  having  arisen, 
and,  had  it  not  been  detected  by  Dr.  Ross,  the  case  might  fairly  enough 
have  been  claimed  as  an  indubitable  example  of  superfoetation. 

Making  every  allowance  for  these  explanations,  there  remain  a  con- 
siderable number  of  cases  which  it  is  very  difficult  to  account  for,  except 
on  the  supposition  that  the  second  child  has  been  conceived  a  consider- 
able time  after  the  first.  Those  interested  in  the  subject  will  find  a  large 
number  of  examples  collected  in  a  valuable  paper  by  Dr.  Bonnar  of 
Cupar.^  He  has  adopted  the  ingenious  plan  of  consulting  the  records 
of  the  British  peerage,  where  the  exact  date  of  the  birth  of  successive 
children  of  peers  is  given,  without,  of  course,  any  reasonable  possibility 
of  error,  and  he  has  collected  numerous  examples  of  births  rapidly  suc- 
ceeding each  other  which  are  apparently  inexplicable  on  any  other 
theory.  In  one  case  he  cites  a  child  was  born  September  12,  1849,  and 
the  mother  gave  birth  to  another  on  January  24,  1850,  after  an  interval 
of  only  127  days.  Subtracting  from  that  14  days,  which  Dr.  Bonnar 
assumes  to  be  the  earliest  possible  period  at  which  a  fresh  impregnation 
can  occur  after  delivery,  we  reduce  the  gestation  to  113  days — that  is,  to 
less  than  four  calendar  months.  As  both  these  children  survived,  the 
second  child  could  not  possibly  have  been  the  result  of  a  fresh  impregna- 
tion after  the  birth  of  the  first ;  nor  could  the  first  child  have  been  a  twin 
prematurely  delivered,  for  if  so,  it  must  have  only  reached  rather  more  than 
the  fifth  month,  at  which  time  its  survival  would  have  been  impossible. 

Besides  the  numerous  examples  of  cases  of  this  kind  recorded  in  most 
obstetric  works,  there  are  one  or  two  of  miscarriage  in  the  early  months, 
in  which,  in  addition  to  a  foetus  of  four  or  five  months'  growth,  a  per- 
fectly fresh  ovum  of  not  more  than  a  month's  development  was  thrown 
off.  One  such  case  was  shown  at  the  Obstetrical  Society  in  1862,  which 
was  reported  on  by  Drs.  Harley  and  Tanner,  who  stated  that  in  their 
opinion  it  was  an  example  of  superfoetation.  A  still  more  conclusive 
case  is  recorded  by  Tyler  Smith  :^  "  A  young  married  woman,  pregnant 
for  the  first  time,  miscarried  at  the  end  of  the  fifth  month,  and  some 
hours  afterward  a  small  clot  was  discharged,  enclosing  a  perfectly 
healthy  ovum  of  about  one  month.  There  were  no  signs  of  a  double 
uterus  in  this  case.  The  patient  had  menstruated  regularly  during  the 
time  she  had  been  pregnant."  This  case  is  of  special  interest  from  the 
fact  of  the  patient  having  menstruated  during  pregnancy — a  circum- 
stance only  explicable  on  the  same  anatomical  grounds  which  render 
superfoetation  possible.  So  far  as  I  know,  it  is  the  only  instance  in 
which  the  coincidence  of  superfoetation  and  menstruation  during  early 
pregnancy  has  been  observed. 

1  Edin.  Med.  Journ.,  1864-65.  ^  3fanual  of  Obsietriei',  p.  112. 


ABNORMAL  PREGNANCY. 


171 


Objections  to  the  Admission  of  Superfostation. — The  objections  to  the 
possibility  of  superfoetation  are  based  on  the  assumptions  that  the 
decidua  so  completely  fills  up  the  uterine  cavity  that  the  passage  of  the 
spermatozoa  is  impossible ;  that  their  passage  is  prevented  by  the  mucous 
plug  which  blocks  up  the  cervix  ;  and  that  when  impregnation  has  taken 
place  ovulation  is  suspended.  It  is,  however,  certain  that  none  of  these 
are  insuperable  obstacles  to  a  second  impregnation.  The  first  was  orig- 
inally based  on  the  older  and  erroneous  view  which  considered  the  de- 
cidua to  be  an  exudation  lining  the  entire  uterine  cavity  and  sealing  up 
the  mouths  of  the  Fallopian  tubes  and  the  aperture  of  the  internal  os  i 
uteri.  The  decidua  reflexa,  however,  does  not  come  into  apposition  with 
the  decidua  vera  until  about  the  eighth  week  o£-,pcegnancy,  and,  there- 
fore, until  that  time  there  is  a  free  space  between  the  two  membranes* 
through  which  the  spermatozoa  might  pass  to  the  open  mouths  of  the 
Fallopian  tube,  and  in  ^vhich  a  newly-impregnated  ovule  might  graft 
itself.  A  reference  to  the  accompanying  figure  of  a  pregnancy  in  the 
third  month,  copied  from  Coste's  work,  will  readily  show  that,  as  far  as 
the  decidua  is  concerned,  there  is  no  mechanical  obstacle  to  the  descent 
and  lodgment  of  another  impregnated  ovule  (Fig.  80).     Then,  as  regards 

Fig.  80. 


Illustrating  the  Cavity  between  the  Decidua  Vera  and  the  Decidua  Reflexa  during  the  Early 
Months  of  Pregnancy.    (After  Coste.) 

the  plug  of  mucus,  it  is  pretty  certain  that  this  is  in  no  way  different 
from  the  mu(;us  filling  the  cervix  in  the  non-pregnant  state,  which  offers 
no  (jbstacle  at  all  to  the  passage  of  the  spermatozoa.  I^astly,  respecting 
the  cessation  of  ovulati(ni  during  pregnancy,  this,  no  doubt,  is  the  rule, 
and  prol)ably  satisfactorily  explains  the  rarity  of  supcrfijetation.  There 
are,  however,  a  sufficient  number  of  authenticated  cases  of  menstruation 
during  pregnancy  to  j)rove  that  ovulation  is  not  always  absolutely  in 


172  PREGNANCY. 

abeyance ;  and,  as  long  as  it  occurs,  there  is  unquestionably  no  positive 
mechanical  obstruction,  at  least  in  the  early  months  of  pregnancy,  in  the 
way  of  the  impregnation  and  lodgment  of  the  ovules  that  are  thrown 

[  oif.     The  reasonable  conclusion,  therefore,  seems  to  be  that,  although  a 
large  majority  of  the  supposed  cases  are  explicable  in  other  ways,  it  can- 

;  not  be  admitted  that  superfcetation  is  either  physiologically  or  mechani- 

/  cally  impossible. 

Extra-uterine  Pregnancy. — The  most  important  of  the  abnormal  vari- 
eties of  pregnancy,  if  we  consider  the  serious  and  very  generally  fatal 
results  attending  it,  is  the  so-called  extra-uterine  foitation,  which  consists 
in  the  arrest  and  development  of  the  ovum  outside  the  cavity  of  the 
uterus.  Of  late  years  this  subject  has  received  much  well-merited  atten- 
tion, which,  it  is  to  be  hoped,  may  lead  to  the  establishment  of  some 
definite  rules  for  the  management  of  this  most  anxious  and  dangerous 
class  of  cases. 

Site  of  Extra-uterine  Pregnancy. — The  ovum  may  be  arrested  and 
developed  in  various  situations  on  its  way  to  the  uterus,  most  commonly 
in  some  J3art  of  tlie  Fallopian  tube,  or  it  may  be  in  the  cavity  of  the 
abdomen,  or  even  quite  beyond  it,  as  in  a  few  rare  cases  in  which  the 
ovum  has  found  its  way  into  a  hernial  sac. 

Classification. — Extra-uterine  gestation  may  be  subdivided  into  the 
following  classes  :  1st,  and  most  common  of  all,  Tubal  gestation,  and,  as 
varieties  of  this,  although  by  some  made  into  distinct  classes,  (ft)  inter- 
stitial  and  (b)  tubo-ovarian  gestation.  In  the  former  of  these  subdivis- 
ions the  ovum  is  arrested  in  the  part  of  the  Fallopian  tube  that  is  situ- 
ated in  the  substance  of  the  uterine  parietes ;  in  the  latter,  at  or  near 
the  fimbriated  extremity  of  the  tube,  so  that  part  of  its  cyst  is  formed 
by  the  tube  and  part  by  the  ovary.  2d.  Abdominal  gestation,  in  which 
an  ovum,  instead  of  finding  its  way  into  the  tube,  falls  into  the  peri- 
toneal cavity,  and  there  becomes  attached  and  developed  ;  or  the  so-called 
secondary  abdominal  gestation,  in  which  an  extra-uterine  pregnancy, 
originally  tubal,  becomes  ventral  through  rupture  of  its  cyst  and  escape 
of  its  contents  into  the  abdominal  cavity.  3d.  Ovarian  gestation,  the 
existence  of  which  is  denied  by  many  writers  of  eminence,  such  as  Yel- 
peau  and  Arthur  Farre,  while  it  is  maintained  by  others  of  equal  celeb- 
rity, such  as  Kiwisch,  Coste,  and  Hecker.  It  must  be  admitted  that  it 
is  extremely  difficult  to  understand  how  an  ovarian  pregnancy,  in  the 
strict  sense  of  the  word,  can  occur,  for  it  implies  that  the  ovule  has  be- 
come impregnated  before  the  laceration  of  the  Graafian  follicle,  through 
the  coats  of  which  the  spermatozoa  must  have  passed.  Coste,  indeed, 
believes  that  this  frequently  happens  ;  but,  while  spermatozoa  have  been 
detected  on  the  surface  of  the  ovary,  their  penetration  into  the  Graafian 
follicle  has  never  been  demonstrated.  Farre  has  also  clearly  sho^n  that 
in  many  cases  of  supposed  ovarian  pregnancy  the  surrounding  structures 
were  so  altered  that  it  was  impossible  to  trace  their  exact  origin  and  to 
say  to  a  certainty  that  the  foetus  was  really  within  the  substance  of  the 
ovary.  Kiwisch  gives  a  reasonable  explanation  of  these  cases  by  sup- 
posing that  sometimes  the  Graafian  follicle  may  rupture,  but  that  the 
ovule  may  remain  within  it  without  being  discharged.  Through  the 
rent  in  the  walls  of  the  follicle  the  spermatozoa  may  reach  and  impreg- 


ABNORMAL  PREGNANCY.  173 

nate  the  ovule,  which  may  develop  in  the  situation  in  which  it  has  been 
detained.  The  subject  has  been  recently  ably  considered  by  Puech,'  who 
admits  two  varieties  of  ovarian  pregnancy,  according  as  the  foetus  has 
developed  in  a  vesicle  which  has  remained  open  or  in  one  which  has 
closed  immediately  after  fecundation.  He  considers  that  most  cases  of 
so-called  ovarian  pregnancy  are  either  dermoid  cysts,  ovario-tubal  preg- 
nancies, or  abdominal  pregnancies  in  which  the  placenta  is  attached  to 
the  ovary,  and  that  even  in  the  rare  cases  of  true  ovarian  pregnancies 
the  progress  and  results  do  not  cliifer  from  those  of  abdominal  preg- 
nancy. While,  therefore,  it  is  impossible  to  deny  the  existence  of  ova- 
rian pregnancy,  it  must  be  considered  to  be  a  very  rare  and  exceptional 
variety,  which,  as  far  as  treatment  and  results  are  concerned,  does  not 
differ  from  tubular  or  abdominal  gestation.  4th.  There  are  two  rare 
varieties  in  which  an  ovum  is  developed  either  in  the  supplementary^  j^jj;^^^^ 
horn  of  a  bilobed  uterus  or  in  a  hernial  sac.  . 

For  the  sake  of  clearness,  we  may  place  these  varieties  of  extra-ute- 
rine gestation  in  the  following  tabular  form : 

1st.  Tubal--  ■ 

(a)  Interstitial,  (b)  Tubo-ovarian. 

2d.  Abdominal — 

(«)  Primary,  (6)  Secondary. 

3d.  Ovarian. 

4th.  In  bilobed  uterus,  hernial,  etc. 

Causes. — The  etiology  of  extra-uterine  foetation  in  any  individual  case 
must  necessarily  be  almost  always  obscure.  Broadly  speaking,  it  may 
be  said  that  extra-uterine  foetation  may  be  produced  by  any  condition 
which  prevents  or  renders  difficult  the  passage  of  the  ovule  to  the  ute- 
rus, while  it  does  not  prevent  the  access  of  the  spermatozoa  to  tlie  ovule. 
Thus,  inflammatory  thickening  of  the  coats  of  the  Fallopian  tiibes  by  i  ,7l^c4a«' 


OC^  «M/ 


lessening  their  calibre,  but  not  sufficiently  so  to  prevent  the  passage  of 
the  spermatozoa,  may  interfere  with  the  movements  of  the  tube  which 
propel  the  ovum  forward,  and  so  cause  its  arrest.     A  similar  effect 
may  be  produced  by  various  morbid  conditions,  such  as  inflammatory^      _____ 
adhesions  from  old-standing  peritonitis  pressing  on  the  tube,  obstriic-  " 

tionj)f  its  calibre  by  inspissated  mucus  or  small  polypoid  growths,  the  3,  '^'^f^_i 
pressure  of  uterine  or  other  tumors,  and  the  like.  The  fact  that  extra- 
uterine pregnancies  occur  most  frequently  in  multiparse,  and  compara- 
tively rarely  in  women  under  thirty  years  of  age,  tends  to  show  that 
these  conditions,  which  are  clearly  more  likely  to  be  met  with  in  such 
women  than  in  young  primiparse,  have  considerable  influence  in  its 
causation.  A  curiously  large  proportion  of  cases  occur  in  women  who  I 
have  either  been  previously  altogether  sterile  or  in  whom  a  long  interval  1 
of  time  has  elapsed  since  their  last  pregnancy.  The  disturbing  effects 
of  fright,  either  during  coition  or  a  few  days  afterward,  have  been 
insisted  on  by  many  authors  as  a  possible  cause.  Numerous  cases  of 
this  kind  are  recorded  ;  and,  although  the  influence  of  emotion  in  the 
production  of  this  condition  is  not  susceptible  of  proof,  it  is  not  difficult 
to  imagine  that  spasms  of  the  Fallopian  tubes  might  be  produced  in  this 
way  which  would  either  interfere  with  the  passage  of  the  ovum  or  direct 

'  Anncd.  de  Oynic,  July,  1878. 


^,'<U.;s 


174  PREGNANCY. 

it  into  the  abdominal  cavity.  The  occurrence  of  abdominal  pregnancy 
is  probably  less  difficult  to  account  for  if  we  admit,  with  Coste,  that  the 
ovule  becomes  impregnated  on  the  surface  of  the  ovary  itself,  for  there 
must  be  very  many  conditions  which  prevent  the  proper  adaptation  of 
the  fimbriated  extremity  of  the  tube  to  the  surface  of  the  ovary,  and 
failing  this  the  ovum  must  of  necessity  drop  into  the  abdominal  cavity. 
Kiwisch  has  pointed  out  that  this  is  particularly  apt  to  occur  when  the 
Graafian  follicle  develops  on  the  posterior  surface  of  the  ovary ;  and, 
indeed,  it  is  probable  that  it  may  be  of  common  occurrence,  and  that 
the  comparative  rarity  of  abdominal  pregnancy  is  due  to  the  difficulty 
with  which  the  impregnated  ovule  engrafts  itself  on  the  surrounding 
viscera.  Impregnation  may  actually  occur  in  the  abdominal  cavity 
itself,  of  which  Keller^  relates  a  remarkable  instance.  In  this  case 
Koeberle  had  removed  the  body  of  the  uterus  and  part  of  the  cervix, 
leaving  the  ovaries.     In  the  portion  of  the  cervix  that  remained  there 

Fig.  81. 


Tubal  Pregnancy,  with  tbe  Corpus  Luteum  in  tlie  Ovary  on  the  opposite  side. 
The  decidua  is  represented  in  the  process  of  detachment  fi'om  tlie  uterine  cavity. 

was  a  fistulous  aperture  opening  into  the  abdominal  cavity  through 
which  semen  passed  and  produced  an  abclominal  gestation.  Several 
curious  cases  are  also  recorded,  which  have  given  rise  to  a  good  deal 
of  discussion,  in  which  a  tubal  pregnancy  existed  while  the  corpus 
luteum  was  on  the  opposite  side  (Fig.  81).  The  most  probable  explana- 
tion, however,  is  that  the  fimbriated  extremity  of  the  tube  in  which  the 
ovum  was  found  had  twisted  across  the  abdominal  cavity  and  gi-asped 
the  opposite  ovary,  in  this  way,  perhaps,  producing  a  flexion  whicli 
impeded  the  progress  of  the  ovum  it  had  received  into  its  canal.  Tyler 
Smith  suggested  that  such  cases  might  be  explained  by  supposing  that 
the  ovum,  after  reaching  the  uterus,  failed  to  graft  itself  in  the  mucous 
membrane,  but  found  its  way  into  the  opposite  Fatlojoian  tube.  Kuss- 
maul^  thinks  that  such  a  passage  of  the  ovum  across  the  uterine  cavity 
may  be  caused  by  muscular  contraction  of  the  uterus,  occurring  shortly 
after  conception,  squeezing  the  yet  free  ovum  upward  toward  the  open- 
ing of  the  opposite  tube,  and  possibly  into  the  tube  itself. 

The  history  and  progress  of  cases  of  extra-uterine  pregnancy  are  mate- 

^  Des  Grossesses  Extra-ulerines,  Paris,  1872.  ^  Mon.f.  Geburt,  Oct.,  1862. 


ABNORMAL  PREGNANCY. 


175 


rially  difFerent  according  to  their  site,  and,  for  practical  purposes,  we  may 
consider  them  as  forming  two  great  classes,  the  tubal  (with  its  varieties) 
and  the  abdominal. 

Tubal  Pregnancies. — When  the  ovum  is  arrested  in  any  part  of  the 
Fallopian  tube,  the  chorion  soon  commences  to  develop  villi,  just  as  in 
ordinary  pregnancy,  which  engraft  themselves  into  the  mucous  lining 
of  the  tube  and  fix  the  ovum  in  its  new  position.  The  mucous  mem- 
brane becomes  hypertrophied,  much  in  the  same  way  as  that  of  the 
uterus  under  similar  circumstances,  so  that  it  becomes  developed  into 
a  sort  of  pseudo-decidua.  Inasmuch,  however,  as  the  mucous  coat  of 
the  tubes  is  not  furnished  with  tubular  glands,  a  true  decidua  can 
scarcely  be  said  to  exist,  nor  is  there  any  growth  of  membrane  around 
the  ovum  analogous  to  the  decidua  retiexa.  The  ovum  is  therefore, 
comparatively  speaking,  loosely  attached  to  its  abnormal  situation,  and 
hence  hemorrhage  from  laceration  of  the  chorion  villi  can  very  readily 
take  place. 

It  is  seldom  that  any  development  of  the  chorion  villi  into  distinct 
placental  structure  is  observed ;  this  is  probably  owing  to  the  fact  that 
laceration  and  death  generally  occur  before  the  period  at  which  the 
placenta  is  normally  formed.  The  muscular  coat  of  the  tube  soon 
becomes  hypertrophied,  and  as  the  size  of  the  ovum  increases  the 
fibres  are  separated  from  each  other,  so  that  tl^  ovum  protrudes  at 

Fig.  82. 


Tubal  Pregnancy.    (From  a  Specimen  in  tlie  Museum  of  King's  (>)Ucge.) 

certain  points  through  them,  and  at  these  it  is  only  covered  by  the 
stretched  and  attenuated  mucous  and  peritoneal  coats  of  the  tube.  At 
this  time  the  tubal  pregnancy  forms  a  smooth  oval  tumor,  which,  as 
a  rule,  ha.s  not  formed  any  adhesions  to  the  surrounding  structures 
(Fig.  82),     The  part  of  the  tube  unoccupied  by  the  ovum   may  be 


176  PREGNANCY. 

found  unaltered,  and  permeable  in  both  directions ;  or,  more  frequently, 

it  becomes  so  stretched  and  altered  that  its  canal  cannot  be  detected. 

Most  frequently  it  is  that  part  of  the  tube  nearest  the  uterus  which 

cannot  be  made  out.     The  condition  of  the  uterus  in  this  as  in  other 

*    forms  of  extra-uterine  pregnancy  has  been  the  subject  of  considerable 

c^^ !   '  1  discussion.     It  is  now  universally  admitted  that  the  uterus  undergoes 

if.-,  uv    a  certain  amount  of  sympathetic  engorgement,  the  cervix  becomes  soft- 

w^^  .      ened,  as  in  natural  pregnancy,  and  the  mucous  membrane  develops  into 

'  I  a  true  decidua.     In  many  cases  the  decidua  is  found  on  post-mortem 

examination,  in  others  it  is  not,  and  hence  the  doubts  that  some  have 

expressed  as  to  its  existence.     The  most  reasonable  explanation  of  its 

absence  is  that  given  by  Duguet,^  who  has  shown  that  it  is  far  from 

uncommon  for  the  uterine  decidua  to  be  thrown  off  en  masse  during  the 

hemorrhagic  discharges  which  so  frequently  precede  the  fatal  issue  of 

extra-uterine  gestation. 

Interstitial  and  False  Ovarian  Pregnancy. — When  the  ovum  is  arrested 
in  that  portion  of  the  tube  passing  through  the  uterus  in  so-called  inter- 
stitial pregnancy,  the  muscular  fibres  of  the  uterus  become  stretched  and 
distended,  and  form  the  outer  covering  of  the  ovum.  When,  on  the 
other  hand,  the  site  of  arrest  is  in  the  fimbriated  extremity  of  the  tube, 
the  containing  cyst  is  formed  partly  of  the  fimbrise  of  the  tube,  partly 
of  ovarian  tissue ;  hei^ce  it  is  much  more  distensible,  and  the  pregnancy 
may  continue  without  laceration  to  a  more  advanced  period,  or  even  to 
term,  so  that  when  the  ovum  is  placed  in  this  situation  the  case  much 
more  nearly  resembles  one  of  abdominal  pregnancy. 

1      Period  at  which  Rupture  occurs. — The  termination  of  tubal  pregnancy, 

I  in  the  immense  majority  of  cases,  is  death,  produced  by  laceration  giving 
rise  either  to  internal  hemorrhage  or  to  subsequent  intense  peritonitis. 

I  Rupture  usually  occurs  at  an  early  period  of  pregnancy,  most  generally 
from  the  fourth  to  the  twelfth  week,  rarely  later.  However,  a  few 
instances  are  recorded  in  which  it  did  not  take  place  until  the  fourth  or 
_  fifth  month,  and  Saxtorph  and  Spiegelberg  have  recorded  apparently 
authentic  cases  in  which  the  pregnancy  advanced  to  term  without  lacera- 
tion. It  is  generally  effected  by  distension  of  the  tube,  which  at  last 
yields  at  the  point  which  is  most  stretched  ;  and  sometimes  it  seems  to 
be  hastened  or  determined  by  accidental  circumstances,  such  as  a  blow 
or  fall  or  the  excitement  of  sexual  intercourse. 

'      Symptoms  of  Rupture. — The  symptoms  accompanying  rupture  are 
those  of  intense  collapse,  often  associated  with  severe  abdominal  pain, 

^  produced  by  the  laceration  of  the  cyst.  The  patient  will  be  found 
deadly:_pale,  with  a  small,  thready,  and  almost  imperceptible^idse,  per- 
haps vomiting,  but  with  mental  faculties  clear.  If  the  hemorrhage  be 
considerable,  she  may  die  without  any  attempt  at  reaction.  Sometimes, 
however — and  this  generally  occurs  in  cases  in  which  the  tube  tears,  the 
ovum  remaining  intact — the  hemorrhage  may  cease  on  account  of  the 
ovum  protruding  through  the  aperture  and  acting  as  a  plug.  The  patient 
may  then  imperfectly  rally,  to  be  again  prostrated  by  a  second  escape  of 
\  blood,  which  proves  fatal.    If  the  loss  of  blood  is  not  of  itself  sufficient 

I  to  cause  death  from  shock  and  anaemia,  the  fatal  issue  is  generally  only 

^  Annates  de  Gynecologie,  May,  1874. 


ABNORMAL  PREGNANCY. 


Ill 


postponed,  for  the  effused  blood  soon  sets  up  a  violent  general.peritonitis,  | 
which  rapidly  carries  off  the  patient.     If  she  should  survive  the  second , 
danger,  the  case  is  transformed  into  one  of  abdominal  pregnancy,  the 
foetus  becoming  surrounded  by  a  capsule  produced  by  inflammatory  exu- 
dation (Fig.  83).     The  case  is  then  subjected  to  the  rules  of  treatment 


Fig.  83. 


Extra-uterine  Pregnancy  at  Term  of  the  Tubo-ovarian  Varietj'.    (After  a  Case  of 
Dr.  A.  Sibley  Campbell's.) 


presently  to  be  discussed  when  considering  that  variety  of  extra-uterine 
gestation. 

Diagnosis. — The  possibility  of  diagnosing  tubal  gestation  before  rup- 
ture occurs  is  a  question  of  great  and  increasing  interest,  from  the  fact 
that,  could  its  existence  be  ascertained,  we  might  very  fairly  hope  to 
avert  the  almost  certainly  fatal  issue  ^vhich  is  awaiting  the  patient.  Un- 
fortunately, the  symptoms  of  tubal  pregnancy  are  always  obscure,  and  too 
often  death  occurs  without  the  slightest  sus])icion  as  to  the  nature  of  the 
ca.se  having  arisen.  In  the  first  place,  it  is  to  be  observed  that  all  the] 
usual  sympatlu'tic  disturbances  of  ])regnaney  exist :  the  breasts  enlarge, 
the  areola?  darken,  and  morning  sickness  is  present.  There  is  also  an 
arrest  of  menstruation,  but  after  the  absence  of  one  or  more  periods 
there  is  often  an  irregular  hemorrhagic  discharge.  This  is  an  important 
symptom,  the  value  of  whi(!h  in  indicating  the  existence  of  tubal  preg- 
nancy has  of  late  years  been  nuich  dwelt  u|)()n  by  various  authors,  both 

12 


178  PREGNANCY. 

in  this  country  and  abroad,  Barnes  attributes  it  to  partial  detachment 
of  the  chorion  villi,  produced  by  the  ovum  growing  out  of  proportion  to 
the  tube  in  which  it  is  contained.  Whether  this  is  the  correct  explana- 
tion or  not,  it  is  a  fact  that  irregular  hemorrhage  very  generally  precedes 
the  laceration  for  several  days  or  more.  Accompanying  this  hemorrhage 
there  is  almost  always  more  or  less  abdominal  pain,  produced  by  the 
stretching  of  the  tissues  in  which  the  ovum  is  placed,  and  this  is  some- 
times described  as  being  of  a  very  intense  and  crampy  character.  If,  then, 
we  meet  with  a  case  in  which  the  symptoms  of  early  pregnancy  exist,  in 
which  there  are  irregular  losses  of  blood,  possibly  discharge  of  mem- 
branous shreds,  and  abdominal  pain,  a  careful  examination  should  be 
insisted  on,  ancl  then  the  true  nature  of  the  case  may  possibly  be  ascer- 
tained. Should  extra-uterine  foetation  exist,  we  should  expect  to  find 
the  uterus  somewhat  enlarged  and  the  cervix  softened,  as  in  early  preg- 
nancy, but  both  these  changes  are  doubtless  generally  less  marked  than 
in  normal  pregnancy.  This  fact,  of  itself,  however,  is  of  little  diag- 
nostic value,  for  slight  differences  of  this  kind  must  always  be  too 
indefinite  to  justify  a  positive  opinion. 

Presence  of  a  Fen-uterine  Tumor. — The  existence  of  a  peri-uterine 
tumor,  rounded  or  oval  in  outline,  and  producing  more  or  less  displace- 
ment of  the  uterus  in  the  direction  opposite  to  that  in  which  the  tumor 
is  situated,  may  point  to  the  existence  of  tubular  foetation.  By  bi- 
manual examination,  one  hand  depressing  the  abdominal  wall,  while  the 
examining  finger  of  the  other  acts  in  concert  with  it  either  through  the 
vagina  or  rectum,  the  size  and  relations  of  the  groMth  may  be  made  out. 
There  are  various  conditions  which  give  rise  to  very  similar  physical 
signs,  such  as  small  ovarian  or  fibroid  growths  or  the  effusion  of  blood 
around  the  uterus ;  and  the  differential  diagnosis  must  always  be  very 
difficult,  and  often  impossible.  A  curious  example  of  the  difficulty  of 
diagnosis  is  recorded  by  Joulin,  in  which  Huguier  and  six  or  seven  of 
the  most  skilled  obstetricians  of  Paris  agreed  on  the  existence  of  extra- 
uterine pregnancy,  and  had,  in  consultation,  sanctioned  an  operation, 
when  the  case  terminated  by  abortion,  and  proved  to  be  a  natural  preg- 
nancy. The  use  of  the  uterine  sound,  which  might  aid  in  clearing  up 
the  case,  is  necessarily  contraindicated  unless  uterine  gestation  is  certainly 
disproved.  Hence  it  must  be  admitted  that  positive  diagnosis  must 
always  be  very  difficult.  So  that  the  most  ^\e  can  say  is,  that  when 
the  general  signs  of  early  pregnancy  are  present,  associated  with  the 
other  symptoms  and  signs  alluded  to,  the  suspicion  of  tubal  pregnancy 
may  be  sufficiently  strong  to  justify  us  in  taking  such  action  as  may 
possibly  spare  the  patient  the  necessarily  fatal  consequence  of  rupture. 

Treatment. — If  the  diagnosis  were  quite  certain,  the  removal  of  the 
entire  Fallopian  tube  and  its  contents  by  abdominal  section  Avould  be 
quite  justifiable,  and  probably  Avould  neither  be  more  difficult  nor  niore 
dangerous  than  ovariotomy ;  "for,  at  this  stage  of  extra-uterine  foetation, 
there  are  no  adhesions  to  complicate  the  operation.  As  yet,  however,  the 
I  uncertainty  of  the  diagnosis  has  prevented  the  adoption  of  the  practice.^ 
■  Opening  of  the  Sac  by  the  Galvano-caustic  Knife. — Dr.  Thomas  of 
New  York^  has  recently  recorded  a  most  instructive  case,  in  which  he 

1  New  York  2Ied.  Journ.,  June,  1875. 


ABNORMAL  PREGNANCY.  179 

saved  the  life  of  the  patient  by  a  bold  and  judicious  operation.  The 
nature  of  the  case  was  rendered  pretty  evident  by  the  signs  above 
described,  and  Thomas  opened  the  cyst  from  the  vagina  by  a  platinum 
knife  rendered  incandescent  by  a  galvano-caustic  battery,  by  which 
means  he  hoped  to  prevent  hemorrhage.  Through  the  opening  thus 
made  he  removed  the  foetus.  In  subsequently  attempting  to  remove 
the  placenta  very  violent  hemorrhage  took  place,  which  was  only  arrested 
by  injecting  the  cyst  with  a  solution  of  persulphate  of  iron.  The  remains 
of  the  placenta  subsequently  came  away  piecemeal,  after  an  attack  of. 
septicaemia,  which  was  kept  within  bounds  by  freely  washing  out  the 
cyst  with  antiseptic  lotion,  the  patient  eventually  recovering.  If  I 
might  venture  to  make  a  criticism  on  a  case  follow^ed  by  so  brilliant 
a  success,  it  would  be  that  in  another  instance  of  this  kind  it  would  be 
safer  to  follow  the  rule  so  strictly  laid  down  with  regard  to  gastrotomy 
in  abdominal  pregnancies,  and  leave  the  placenta  untouched,  trusting 
to  the  injection  of  antiseptics  and  the  thorough  drainage  of  the  cyst  to 
prevent  mischief.  [^] 

[The  advice  given  by  the  author  in  regard  to  the  non-removal  of  the 
placenta  was  first  urged  upon  the  medical  profession  in  1791  by  Mr. 
William  Trumbull  in  a  paper  read  before  the  Medical  Society  of  London, 
and  again  in  1795,  in  a  letter^  from  the  late  Dr.  James  Mease  of  Phila- 
delphia to  Dr.  Lettsom  of  London,  in  which  he  reported  an  operation 
by  Dr.  Charles  McKnight  of  New  York  very  similar  to  this  of  Dr. 
Thomas,  and  ending  favorably  to  the  woman.  The  remarks  of  Dr. 
Mease  on  the  impropriety  of  removing  the  placenta  were  read  before  the 
same  society,  and  concurred  in  by  some  of  the  members  present. 

It  is  a  little  remarkable  that  the  opinion  of  Dr.  Mease  originated  in 
an  accident  which  occurred  in  the  operation  of  Dr.  McKnight,  by  Avhich 
the  funis  was  ruptured,  and  in  consequence  of  which  the  placenta,  which 
was  outside  of  the  cyst,  could  not  be  found  for  removal.  The  value  of 
this  discovery  appears  to  have  been  lost  to  the  profession  for  a  long  term 
of  years,  as  many  authors  have  objected  to  the  operation  because  of  the 
danger  of  removing  the  placenta. 

In  a  second  operation,  performed  on  May  10,  1876,  in  a  case  of 
secondary  abdominal  pregnancy,  Dr.  Thomas^  operated  through  the 
linea  alba,  and  removed  a  female  foetus  weighing  6  lbs.  15  oz. 
The  funis  was  traced  to  the  left  iliac  fossa,  where  it  was  apparently 
inserted  into  the  peritoneum,  and  no  placenta  was  discernible.  The 
cord  was  cut  off  at  its  origin,  and  the  wound  closed,  except  at  its  lower 
part,  which  was  kept  open  by  a  glass  tube.  The  woman's  pulse  before 
the  operation  was  120,  and  fell  to  107  at  the  end  of  the  first  week; 
temperature  was  always  100°  and  upward,  but  in  the  middle  of  the 

['  Dr.  .J.  IT.  Mathieson  of  St.  Mary's,  Ontario,  performed  a  similar  operation  on  June 
28,  1881,  and,  as  in  the  Kin^i;  ease  of  Edisto  Island  in  IBHi,  saved  both  mother  and 
(o'tuH.  The  subject  was  a  woman  of  .'»(),  and  prcf;n;int  for  the  sixth  time.  After  open- 
\\\'^  the  vaj^ina  the  fo-tus,  which  weif^hed  8  lbs.  1\  o/,.,  was  delivered  by  the  forcejjs. 
The  placenta,  which  was  thrce-lobed,  was  easily  peeled  oflj  and  a  sponge  soa,ked  with 
solution  of  perchloride  of  iron  was  inserted.  There  was  not  much  hemorrhage,  and 
tlie  cyst  was  treated  with  antiseptic  syringing.  It  was  three  months  in  closing  up 
{Tram.  OlMcirk  Soc.  London,  May  7,  1884;  Lancet,  May  24,  1884,  p.  940).— Eu.]  ' 

[''  MemoivH  of  Med.  SoC.  London,  vol.  iv.  {).  .S42,  1795.] 

[•'  Am.  Joij.ru.  of  Obnlelricn,  vol.  ix.  [).  (iOf),  1876.] 


180  PREGNANCY. 

fourth  week  it  rose  to  103°-104°,  and  the  pulse  to  130.  The  placenta 
was  found  presenting  at  the  opening  in  the  abdomen,  and  was  removed 
with  dressing  forceps.  It  was  of  the  ordinary  diameter  and  had  a 
shrivelled  appearance.  The  removal  afforded  a  decided  relief,  and  the 
temperature  tell  within  three  hours.  Antiseptic  injections  were  freely 
used  in  the  treatment  of  the  case,  and  the  patient  made  a  good  re- 
covery. 

Prof.  T.  Gaillard  Thomas,  above  referred  to,  has  reported^  27  cases  of 
extra-uterine  pregnancy  which  have  come  under  his  personal  observation, 
all  but  3  of  them  having  been  seen  in  consultation.  Of  these,  17  re- 
covered and  10  died.  Rupture  of  the  sac  occurred  in  7  cases,  with  6 
deaths.  Laparotomy  was  jDcrformed  in  5  cases,  4  of  ^hich  recovered. 
In  2  women  the  cysts  ^vere  tapped,  and  both  died.  One  cyst  Mas  incised 
by  the  thermo-cautery  per  vaginam,  with  recovery,  and  one  was  evacu- 
ated per  rectum,  but  the  patient  died.  Two  recovered  after  spontaneous 
evacuation  by  the  rectum,  and  3  Mere  cured  by  destroying  the  foetus 
under  galvanism.  Prof  Goodell  of  Philadelphia  reports  13  cases,  M^ith 
3  recoveries.^ — Ed.] 

Means  of  Destroying  the  VitaUty  of  the  Foetus. — Another  mode  of 
managing  these  cases  is  to  destroy  the  foetus,  so  as  to  check  its  further 
growth,  in  the  hope  that  it  may  remain  inert  and  passive  within  its  sac. 
Various  operations  have  been  suggested  and  practised  for  this  purpose. 
Thus,  needles  have  been  introduced  into  the  tumor,  through  Avhich 
currents  of  electricity  have  been  passed,  either  the  continuous  current, 
or,  as  has  been  suggested  by  Duchenne,  a  spark  of  Franklinic  electricity. 
Hicks,  Allen,  and  others  have  endeavored  to  destroy  the  foetus  by 
jDassing  an  electro-magnetic  current  through  it  by  means  of  a  needle,  p] 
Lusk^  relates  several  successful  cases  following  the  use  of  the  faradic 
current,  one  pole  being  passed  through  the  rectum  to  the  site  of  the 
ovum,  the  other  being  placed  on  a  point  in  the  abdominal  Mall  tMO  or 
three  inches  above  Poupart's  ligament.  The  current  should  be  passed 
daily  for  five  or  ten  minutes,  and  continued  for  a  Mcek  or  tMO  until  the 
shrinking  of  the  tumor  gives  satisfactory  evidence  of  the  death  of  the 
foetus.  In  a  case  reported  by  Dr.  Bachetti,  in  Mhich  the  continuous 
current  was  used,  the  groMi:h  of  the  ovum  Mas  arrested  and  the  patient 
recovered.  The  same  result,  hoM'ever,  Mould  probably  have  folloM'ed 
the  simple  puncture  of  the  cyst.  This  has  been  successfully  practised 
on  several  occasions,  either  Mdth  a  small  trocar  and  canula  or  ^^'ith  a 
simple  needle.  A  very  interesting  case,  in  M^iich  the  development  of  a 
tM'O  months'  tubal  gestation  M^as  arrested  in  this  M^ay,  is  recorded  by 
Greenhalgh,^  and  another  by  Martin  of  Berlin^.  Joulin  suggested  that 
not  only  should  the  cyst  be  jiunctured,  but  that  a  solution  of  morphia 
jshould  he  injected  into  it,  Mhich,  l)y  its  toxic  influence.  Mould  ensure  the 
'  destruction  of  the  foetus ;  and  this  is  probably  one  of  the  best  means  at 
our  disposal  for  destroying  the  foetus.  Other  means  proposed  for  effect- 
ing the  same  object,  such  as  pressure  or  the  administration  of  toxic 

[1  Tmns.  Am.  Gyntecol.  Snc,  vol.  vii..  for  1882.  and  vol.  ix.,  for  1884.]  [-  Ihicl.] 

[^  Dr.  Allen  did  not  use  needles  in  applying  the  current. — Ed.] 

^  Science  and  Art  of  Midwifery,  p.  321. 

^Lancet,  1867.  ^  Monat.f.  Gehurl,  1868. 


ABNORMAL  PREGNANCY. 


181 


remedies  by  the  mouth,  are  far  too  uncertain  to  be  relied  on.  The 
simplest  and  most  eifectual  plan  would  be  to  introduce  the  needle  of 
an  aspirator,  by  which  the  liquor  amnii  would  be  drawn  oif  and  the 
further  growth  of  the  foetus  effectually  prevented.  Parry,^  indeed,  is 
opposed  to  this  practice,  and  has  collected  several  cases  in  which  the 
puncture  of  the  cyst  was  followed  by  fatal  results,  either  from  hemorrhage 
or  septicaemia.  In  these,  however,  an  ordinary  trocar  and  canula  >vere 
probably  employed,  which  would  necessarily  admit  air  into  the  sac.  It 
is  difficult  to  imagine  that  a  fine  hair-like  aspirating  needle,  rendered 
perfectly  aseptic  by  carbolic  acid,  could  have  any  injurious  results ;  and 
it  could  do  no  harm,  even  if  an  error  of  diagnosis  had  been  made  and 
the  suspected  extra-uterine  foetation  turned  out  to  be  some  other  sort  of 
growth.  If  the  aspirator  proves  that  an  extra-uterine  foBtation  exists, 
then,  if  the  cyst  be  of  any  considerable  size,  and  the  pregnancy  ad- 
vanced beyond  the  second  month,  we  might,  if  deemed  advisable, 
resort  to  a  more  radical  operation,  such  as  that  so  successfully  practised 
by  Thomas. 

[The  safest  and  most  successful  of  all  the  methods  that  have  been  \ 
employed  for  arresting  the  development  of  an  extra-uterine  foetus  is  that 
of  the  galvanic  current,  for  the  efficient  use  of  which  needles  and  punc- 
turing are  not  at  all  necessary.  This  operation  has  been  more  frequently 
reported  in  the  United  States  than  in  any  other  country,  and  of  15  cases 
on  record  not  one  was  fatal.  Dr.  Henry  J.  Garrigues  of  New  York 
City  thus  describes  his  method  of  operating:^  "I  used  a  French  one- 
cell  apparatus,  composed  of  two  carbon  plates  and  one  zinc  plate  im- 
mersed in  Bunsen's  battery  fluid  (potass,  bichrom.  51]  ;  acid  sulphuric, 
concentr.  fsiss ;  aquse  fluv.  f.?xj).  The  positive  electrode,  made  of  a 
large  carbon  plate,  covered  with  cloth,  was  applied  on  the  abdomen  over 
the  tumor.  The  negative  electrode,  consisting  of  one  insulated  brass 
stem,  with  knob,  was  introduced  into  the  vagina  and  pressed  up  against 
the  lower  part  of  the  tumor.  The  current  was  gradually  increased  to 
the  limit  of  her  endurance,  but  never  enough  to  cause  real  pain."  Two 
days  later  the  pulsation  of  the  tumor  previously  felt  in  the  vagina  had 
disappeared,  and  the  tumor  was  less  in  size.  The  applications  were  made 
for  ten  minutes  almost  daily  for  two  weeks.  In  sixteen  days  the  tumor 
had  diminished  to  the  size  of  an  English  walnut. — Ed. 

Treatment  rvhen  Riq^ture  has  Occurred. — AVhen  the  chance  of  arrest- 
ing the  growth  of  a  tubular  foetation  has  never  arisen,  and  we  first  rec- 
ognize its  existence  after  laceration  has  occurred  and  the  jJfitient  is  col- 
lapsed from  hemorrhage,  what  course  are  we  to  pursue?  Hitherto,  all 
that  ever  has  been  done  is  to  attempt  to  rally  the  patient  by  stimulants, 
and,  in  the  unlikely  event  of  her  surviving  the  immediate  effiscts  of  lace- 
ration, endeavoring  to  control  the  subsequent  peritonitis,  in  the  hope 
that  the  cffiiscKl  blood  may  become  absorbed,  as  in  pelvic  hematocele. 
This  is,  indf.'C'd,  a  frail  reed  to  rest  upon,  and  when  laceration  of  a  tubal 
gestation,  advanced  beyond  a  month,  has  occurred,  death  has  l)cen  the 
most  certain  result.  It  is  supjwsed  by  Bernutz — and  his  opinion  is  shared 
by  Barnes — that  rupture  which  does  not  prove  fatal  is  probably  not  very 


'  I'iirry  on  Ertra-uterine  Prer/navcy,  ]).  204. 
['^  TraiiH.  Am.  (iyiKrrnl.  Soc,  vol.  vii.,  lor  I.SS2 


182  PREGNANCY. 

rare  in  the  first  few  days  of  extra-uterine  gestation,  and  that  it  is  not  an 
uncommon  cause  of  certain  forms  of  pelvic  hsematocele.  It  has  more 
than  once  being  suggested  that  it  would  be  perfectly  justifiable  when 
laceration  has  occurred  to  perform  gastrotomy,  to  sponge  away  the 
effused  blood,  and  to  place  a  ligature  around  tlie  lacerated  tube  and 
remove  it  ^\\\\\  its  contents.  This  would  no  doul)t  be  a  bold  and  heroic 
procedure,  but  no  one  who  is  acquainted  with  the  triumphs  of  modern 
abdominal  surgery  can  say  that  it  would  be  either  impossible  or  hopeless. 
The  sponging  out  of  effused  blood  from  the  abdominal  cavity  is  an 
every-day  procedure  in  ovariotomy,  nor  is  there  any  apparent  difficulty 
in  ligaturing  and  removing  the  sac  of  the  extra-uterine  pregnancy,  for, 
as  a  rule,  there  are  no  adhesions  formed  to  the  surrounding  parts.  The 
history  of  these  cases  shows  that  death  does  not  generally  follow  rupture 
for  some  hours,  so  that  there  would  be  usually  time  for  the  operation, 
and  the  extreme  prostration  might  be,  perhaps,  temporarily  counteracted 
by  transfusion.  Pressure  on  the  abdominal  aorta,  resorted  to  when  the 
patient  is  first  seen,  might  possibly  be  employed  A^dth  advantage  to  check 
further  hemorrhage  until  the  question  of  operation  is  decided.  We  must 
remember  that  the  alternative  is  death,  and  hence  any  operation  which 
would  afford  the  slightest  hope  of  success  would  be  perfectly  justifiable. 
I  cannot,  therefore,  agree  with  those  who  hold  that  because  the  chances 
of  success  are  so  small  the  operation  should  not  be  tried ;  and  I  do  not 
doubt  that  it  will  yet  fall  to  the  lot  of  some  one  by  this  means  to  snatch 
a  patient  from  the  jaws  of  death  and  still  further  to  extend  the  successes 
of  abdominal  surgery. 

[This  has  already  been  done  upon  four  occasions,  thanks  to  the  bold- 
ness and  skill  of  Mr.  Lawson  Tait  of  Birmingham,  who  has  operated 
five  times,  losing  only  the  first  patient.  These  operations  bear  the  dates 
of  Jan.  17,  1883  ;  March  1,  1884 ;  April  9,  1884 ;  May  25,  1884 ;  and 
June  5,  1884.^  There  was  no  later  one  up  to  October  1,  1884.  Thus, 
in  four  consecutive  months  there  were  four  women  saved  from  death 
by  internal  hemorrhage  following  rupture  of  Fallopian  foetal  cysts.  In 
theory,  this  operation  has  long  been  viewed  as  giving  promise  of  suc- 
cess. Promptness,  boldness,  and  the  advantage  of  an  early  rupture  were 
the  requisites ;  but  permission  to  operate  and  agreement  in  consultation 
upon  the  case  presented  were  the  obstacles  to  be  overcome.  I  became 
fully  convinced  of  the  practicability  of  this  measure  in  making  an 
autopsy  of  a  young  married  lady  in  1 856,  in  whom  a  cyst  had  burst 
at  about  the  fourth  week,  causing  her  death  in  twenty-three  hours.  In 
that  day  no  one  would  have  dared  to  operate  in  such  a  case,  and,  besides, 
all  of  the  three  physicians  Avho  saw  her  under  the  attack  believed  she 
was  not  pregnant,  as  she  was  menstruating.  The  history  of  the  case,  as 
given  to  me,  indicated  to  my  mind  that  there  had  been  a  rupture  of  the 
right  Fallopian  tube ;  which  proved  to  be  correct.  In  the  last  edition 
of  this  work  I  referred  to  a  case  upon  which  Prof.  T.  Gaillard  Thomas 
of  New  York  would  have  operated  had  he  not  been  overruled  by  several 
physicians  in  consultation,  who  were  doubtful  of  the  correctness  of  his 
diagnosis  and  feared  to  have  it  tested  under  the  knife.  In  another  case 
in  New  York  the  patient  was  operated  upon  by  Dr.  Charles  K.  Briddon, 

[1  British  Med.  Jnurn.,  June  23,  1884,  p.  1250.] 


ABNORMAL  PREGNANCY.  183 

but  the  delay  in  getting  a  consultation  and  the  final  consent  of  the  family 
was  fatal  to  her :  she  lived  forty-seven  hours,  but  never  reacted.  At  7 
p.  M.  she  was  pulseless  and  thought  herself  dying ;  at  9  p.  m.  a  consulta- 
tion was  held,  and  at  9.30  a  second,  with  a  third  consultant.  Then  the 
family  had  to  consent,  and  thus  hours  of  vital  moment  were  lost.^  This 
success  of  Mr.  Tait  will  open  the  way  for  the  performance  of  the  opera- 
tion by  others. — Ed.] 

Ahdommal  Pregnancy. — In  the  second  of  the  two  classes  into  which, 
for  practical  convenience,  we  have  divided  extra-uterine  gestation,  the 
ovum  is  developed  in  the  abdominal  cavity.  It  is  as  yet  an  open  ques- 
tion whether  in  some  cases  the  pregnancy  is  primarily  abdominal  or  not. 
Barnes  believes  that  it  probably  never  is  so,  on  account  of  the  difficulty 
of  admitting  that  so  minute  a  body  as  the  ovum  should  be  able  to  fix 
itself  on  the  smooth  peritoneal  surface.  He  therefore  thinks  that  all 
abdominal  pregnancies  are  primarily  either  tubal  or  ovarian,  the  sac  in 
which  they  were  contained  having  given  way,  and  the  ovum  having 
retained  its  vitality  through  partial  attachment  to  the  original  sac.  This 
theory  is  opposed  to  that  of  the  majority  of  writers,  and,  although  it 
may  perhaps  render  the  facts  less  difficult  to  understand,  it  is  purely 
hypothetical.  There  is  no  evidence  to  show  that  in  most  cases  there  is 
an  early  laceration  of  a  tubal  or  ovarian  sac.  That  the  chorion  villi  do 
graft  themselves  upon  the  surrounding  peritoneum  is  certain,  and  is 
observed  in  all  cases  of  abdominal  gestation.  It  is  not  more  difficult 
to  imagine  them  doing  this  from  their  very  first  development  than  a 
little  later ;  for  it  must  be  allowed  that  if  such  laceration  does  occur,  in 
most  cases  it  can  only  be  when  pregnancy  is  very  slightly  advanced.  On 
the  whole,  therefore,  it  seems  not  unreasonable  to  admit  the  usual  explana- 
tion of  these  cases,  that  the  ovule,  already  impregnated,  escaped  the  grasp 
of  the  Fallopian  tube  and  fell  into  the  abdominal  cavity,  where  it  rooted 
itself  and  developed.  Some  have,  indeed,  supposed  that  abdominal  preg- 
nancy may  occasionally  arise  in  consequence  of  spermatozoa  finding 
their  way  into  the  peritoneal  cavity,  and  there  meeting  and  impregnat- 
ing an  ovule  discharged  from  the  Graafian  follicle.  Such  an  event  one 
would  suppose  to  be  almost  impossible,  but  Koeberle's  case,  already 
quoted,  proves  that  it  has*  actually  occurred.  The  probability  is  that  it 
is  by  no  means  rare  for  impregnated  ovules  to  drop  into  the  peritoneal 
cavity,  and  that  the  majority  of  those  that  do  so  perish  without  doing 
any  harm.  When  they  do  survive,  however,  the  chorion  villi  sprout, 
attach  themselves  to  the  surrounding  structures,  and  eventually  develop 
int<^  a  placenta.  The  mode  in  Avhich  the  chorion  villi  are  attached,  and 
the  arrangement  of  the  maternal  blood-vessels,  have,  never  yet  been 
worked  out,  and  would  form  a  very  interesting  subject  for  investigation. 
The  precise  seat  of  attachment  varies,  and  the  placenta  has  been  found 
fixed  to  most  of  the  abdominal  viscera,  either  those  contained  in  the 
pelvis  pr()))er,  or  it  may  be  the  intestines,  or  to  the  iliac  fossa;  most 
frequently,  aj)parently,  the  ovum  finds  its  way  into  the  retro-uterine 
cul-de-sac. 

ForiiKifioii  of  (t  ( 'if.st  n/rouvd  the  Oiu(/ia. — Tlie  subsequent  changes  vary 
niiicli.      In  the  large  majority  of  cases  th(!  ovum  produces  considerable 

l^  Medical  Newti,  Pliil.a.,  Dec.  15,  18,S3,  p.  066.] 


184  PllEd  NANCY. 

irritation,  resulting  in  the  exudation  of  plastic  material,  which  is  thrown 
round  it,  so  as  to  form  a  secondary  cyst  or  capsule  in  which  maternal 
vessels  are  largely  developed,  and  which  stretches,  jpari  passu,  with  the 
growth  of  the  ovum  (Fig.  84).  The  density  and  strength  of  this  cyst 
are  found  to  be  very  different  in  different  cases ;  sometimes  it  forms  a 
complete  and  strong  covering  to  the  ovum,  at  others  it  is  very  thin  and 

Fig.  84. 


Uteri.it;  and  F(jetiis  in  a  Case  of  Abdominal  Pregnancy. 

only  partially  developed,  but  it  is  rarely  entirely  absent.  As  there  is 
ample  space  for  the  development  of  the  ovum,  and  as  the  secondary  cyst 
generally  stretches  and  grows  along  with  it,  most  cases  of  abdominal 
pregnancy  progress  without  any  very  remarkable  symptoms,  beyond 
occasional  severe  attacks  of  pain,  until  the  full  term  of  pregnancy  has 
been  reached.  Sometimes,  however,  the  cyst  lacerates,  and  there  is  an- 
escape  of  blood  into  the  abdominal  cavity,  accompanied  by  more  or  less 
prostration  and  collapse,  which  may  prove  fatal,  but  from  which  the 
patient  more  generally  rallies.  The  foetus,  now  dead,  will  remain  in  the 
abdomen,  and  will  undergo  changes  and  produce  results  similar  to  those 
which  we  shall  presently  describe  as  occurring  in  cases  progressing  to  the 
full  period. 

Pseudo-lahoji^omstimes  Comes  on. — In  most  cases,  at  the  natural 
termination  of  pregnancy  a  strange  series  of  phenomena  occur  :  pseudo- 
labor  comes  on,  there  are  more  or  less  frequent  and  strong  uterine  con- 
tractions, possibly  an  escape  of  blood  from  the  vagina,  the  discharge  of 
the  broken-down  uterine  decidua,  and  even  the  establishment  of  lacta- 
tion. Sometimes  the  contractions  of  the  abdominal  muscles  produced 
by  this  ineffective  labor  have  been  so  strong  as  to  cause  the^laceration 
of  the  adventitious  cyst  surrounding  the  foetus,  and  the  escape  of  blood 
and  liquor  amnii  into  the  abdominal  cavity,  with  a  rapidly  fatal  result. 
More  frequently  laceration  does  not  occur,  and  the  sjrarious  labor-pains 
continue  at  intervals  imtil  the  foetus  dies,  possibly  from  pressure,  but 
more  often  from  effusion  of  blood  into  the  tissue  of  the  placenta,  and 
consequent  asphyxia.     Occasionally  the  foetus  has  apparently  lived  a 


ABNORMAL  PREGNANCY. 


185 


considerable  time,  in  some  cases  even  for  several  months,  after  the  nat- 
ural limit  of  pregnancy  has  been  reached. 

Changes  After  the  Death  of  the  Foetus. — It  is  after  the  death  of  the 
foetus  that  the  dangers  of  abdominal  pregnancy  generally  commence,  and 
they  are  numerous  and  various.  The  subsequent  changes  that  occur  are 
well  worthy  of  study.  Occasionally  the  foetus  has  been  retained  for  a 
length  of  time,  even  until  the  end  of  a  long  life,  without  producing  any 
serious  discomfort,  and  in  many  cases  of  this  kind  several  normal  preg- 
nancies and  deliveries  have  subsequently  taken  place.  Even  when  the 
extra-uterine  gestation  appears  to  be  tolerated,  and  has  remained  a  long 
time  without  producing  any  bad  effects,  serious  symptoms  may  be  sud- 
denly developed,  so  that  no  woman,  under  such  circumstances,  can  be 
considered  safe.  The  condition  of  these  retained  foetuses  varies  much. 
Most  commonly  the  liquor  amnii  is  absorbed,  the  foetus  slu'inks  and  dies, 
all  its  soft  structures  are  changed  into  adipocere,  and  the  bones  only  re- 
main unaltered.  Sometimes  this  change  occurs  with  great  rapidity.  I 
have  elsewhere '  recorded  a  case  of  extra-uterine  foetation  in  which  at  the 
full  term  of  pregnancy  the  foetus  was  alive,  and  the  woman  died  in  less 
than  a  year  afterward.  On  post-mortem  examination  the  foetus  was 
found  entirely  transformed  into  a  greasy  mass  of  adipocere,  studded 
with  foetal  bones,  in  which  not  a  trace  of  any  of  the  soft  parts  could  be 
detected.  On  the  other  hand,  the  foetus  may  remain  unchanged  :  in  the 
Museum  of  the  College  of  Surgeons  there  is  one  which  was  retained  in 
the  abdomen  for  fifty-two  years,  and  which  was  found  to  be  as  fresh  and 
unaltered  as  a  new-born  child.  In  other  cases  the  sac  and  its  contents 
atrophy  and  shrink,  and  calcareous  matter  is  deposited  in  them,  so  that 
the  whole  becomes  converted  into  a  solid  mass  known  as  IWigpcecUon . 
(Fig.  85).  The  cases,  however,  in  which  the  retention  of  the  foetus 
gives  rise  to  no  mischief  are  quite  excep- 
tional. Generally  the  foetus  putrefies,  and 
this  may  either  immediately  cause  fatal  peri- 
tonitis or  septicaemia,  or,  as  more  commonly 
happens,  secondary  inflammation  and  sup- 
puration of  the  sac.  Under  the  influence  of 
the  latter  the  sac  opens  externally,  either 
directly  at  some  point  of  the  abdominal 
walls  or  indirectly  through  the  vagina,  the 
b(J^vels,  or  even  the  bladder.  Through  the 
aperture  or  apertures  thus  formed  (for  there 
are  often  several  fistulous  openings)  pus  and 
the  bones  and  other  parts  of  the  broken- 
down  fffitus  are  discharged ;  and  this  may 
go  on  for  montlis,  and  even  years,  until  at 
last,  if  the  patient's  strength  does  not  give 
way,  the  whole  contents  of  the  cyst  are  ex- 
fK'lled,  and  recovery  takes  place.  From 
various  statistical    observations    it   appears  (i'''"""i I'leii'i'it'""  •"  t'lo '*i"f"" "'" 

,  ,  ,  ,.  1,1  *""  OolleKe  of  Surseniis.) 

that  the  cliances  oi  recovery  are  best  when 

the  cyst  opens  through  the  abdominal  walls,  next  tlii-oiigli  the  vagina  or 

'  OhL  Trans.,  vol.  vii. 


Fig. 85. 


I.itliopifdinn. 


186  PREGNANCY. 

bladder,  and  that  the  foetus  is  discharged  with  most  difficulty  and  danger 
when  the  aperture  is  formed  into  the  bowel.  At  the  best,  however,  the 
process  is  long,  tedious,  and  full  of  danger  ;  and  the  patient  too  often 
sinks,  during  the  attempt  at  expulsion,  through  the  irritation  and  exhaus- 
tion produced  by  the  abundant  and  long-continued  discharge. 

Diagnosis. — The  diagnosis  of  abdominal  gestation  is  by  no  means  so 
easy  as  might  be  thought,  and  the  most  experienced  practitioners  have 
been  mistaken  with  regard  to  it. 

The  most  characteristic  symptom,  although  this  is  not  so  common  as 
in  tubal  gestation,  is  metrorrhagia  combined  with  the  general  signs  of 
.  pregnancy.  Very  severe  and  frequently-repeated  attacks  of  abdominal 
pain  are  rarely  absent,  and  should  at  once  cause  suspicion,  especially  if 
associated  with  hemorrhage  and  the  discharge  of  a  decidual  membrane 
from  the  uterus.  They  are  supposed  by  some  to  depend  on  intercurrent 
attacks  of  peritonitis,  by  which  the  foetal  cyst  is  formed.  Parry  doubts 
this  explanation,  and  attributes  them  partly  to  the  distension  of  the  cyst 
by  the  growing  foetus,  and  partly  to  pressure  on  the  surrounding  struc- 
tures. On  palpation  the  form  of  the  abdomen  will  be  observed  to  differ 
from  that  of  normal  pregnancy,  being  generally  more  developed  in  the 
transverse  direction,  and  the  rounded  outline  of  the  gravid  uterus  cannot 
be  detected.  AVhen  development  has  advanced  nearly  to  term,  the 
extreme  distinctness  with  which  the  foetal  limbs  can  be  felt  will  arouse 
suspicion.  Per  vaginam,  the  os  and  cervix  will  be  felt  softened,  as  in 
:  ordinary  pregnancy,  but  often  displaced  by  the  pressure  of  the  cyst,  and 
'■  sometimes  fixed  by  perimetritic  adhesions ;  either  of  these  signs  is  of 
great  diagnostic  value. 

By  bi-manual  examination  it  may  be  possible  to  make  out  that  the 
uterus  is  not  greatly  enlarged,  and  that  it  is  distinctly  separate  from  the 
bulk  of  the  tumor ;  these  facts,  if  recognized,  would  of  themselves  dis- 
prove the  existence  of  uterine  gestation.  The  diagnosis,  if  the  foetal 
limbs  or  heart-sounds  could  be  detected,  would  be  cleared  up  in  any  case 
by  the  uterine  sound,  which  would  show  that  the  uterus  was  empty  and 
only  slightly  elongated.  But  we  must  be  careful  not  to  resort  to  this 
test  unless  the  existence  of  uterine  gestation  is  positively  disproved  by 
other  means.  As,  however,  it  places  the  diagnosis  beyond  a  doubt,  it 
should  always  be  employed  whenever  operative  procedure  is  in  contem- 
plation. Quite  recently  I  have  seen  a  remarkable  case  which  illustrates 
the  importance  of  this  rule.  The  case  had  been  diagnosed  as  abdominal 
pregnancy  by  no  less  than  six  experienced  practitioners,  and  was  actually 
on  the  operating-table  for  the  performance  of  laparotomy.  As  a  precau- 
tion, having  some  doubts  of  the  diagnosis,  I  suggested  the  passage  of  the 
sound,  ^vhich  entered  into  a  gravid  uterus,  the  case  proving  to  be  one 
of  small  ovarian  tumor  jammed  down  into  Douglas's  space  and  displa- 
cing the  cervix  forward.  Had  it  not  been  for  this  precaution  its  true 
nature  would  certainly  not  have  been  detected. 

Treatment. — The  treatment  of  abdominal  gestation  will  always  be  a 

subject  of  anxious  consideration,  and  there  is  much  difference  of  opinion 

as  to  the  proper  course  to  pursue.     It  is  pretty  generally  admitted  that 

I  it  is  not  advisable  to  adopt  any  active  measures  until  the  full  term  of 

)  development  is  reached.     Puncturing  the  cyst,  with  the  view  of  destroy- 


ABNORMAL  PREGNANCY.  187 

ing  the  foetus  and  arresting  its  further  growth,  has  been  practised,  but 
tliere  are  good  grounds  for  rejecting  it,  for  there  is  not  the  same  immi- 
nent risk  of  death  from  rupture  of  the  cyst  as  in  tubal  foetation ;  and 
even  if  the  destruction  of  the  foetus  could  be  brought  about,  there  would 
still  be  formidable  dangers  from  subsequent  attempts  at  elimination  or 
from  internal  hemorrhage. 

Question  as  to  the  Performance  of  Primary  Gastrotomy. — When  the  i  /..w^--'  ^-- 
full  period  has  arrived,  the  child  being  still  alive,  as  proved  by  auscul-  ''-■:i^J^^viiy 
tation,  we  have  to  consider  whether  it  may  not  be  advisable  to  perform  ____«..^ 
gastrotomy  before  the  foetus  perishes,  and  so  at  least  save  the  life  of  the 
child.  There  are  few  questions  of  greater  importance  and  more  difficult 
to  settle.  The  tendency  of  medical  opinion  is  rather  in  favor  of  immedi- 
ate operation,  which  is  recommended  by  Velpeau,  Kiwisch,  Koeberle, 
Schroeder,  and  many  other  writers,  whose  opinion  necessarily  carries 
great  weight.  The  arguments  used  in  favor  of  immediate  operation  are, 
that  while  it  affijrds  a  probability  of  saving  the  child,  the  risks  to  the 
mother,  great  though  they  undoubtedly  are,  are  not  greater  than  those 
which  may  be  anticipated  by  delay.  If  we  put  off  interference,  the  cyst 
may  rupture  during  the  ineffectual  efforts  at  labor,  and  death  at  once 
ensue ;  or,  if  this  does  not  take  place,  other  risks,  which  can  never  be 
foreseen,  are  always  in  store  for  the  patient.  She  may  sink  from  peri- 
tonitis, or  from  exhaustion,  consequent  on  the  efforts  at  elimination, 
which  in  the  majority  of  cases  are  sooner  or  later  set  up,  so  that,  as 
Barnes  properly  says,  "  the  patient's  life  may  be  said  to  be  at  the  mercy 
of  accidents  of  which  we  have  no  sufficient  warning."  On  the  other 
hand,  if  we  delay,  while  we  sacrifice  all  hope  of  saving  the  child,  we  at 
least  give  the  mother  the  chance  of  the  foetation  remaining  quiescent  for 
a  length  of  time,  as  certainly  not  unfrequently  occurs.  Thus,  Campbell 
collected  62  cases  of  ultimate  recovery  after  abdominal  gestation,  in  21 
of  which  the  foetus  was  retained  without  injury  for  a  number  of  years. 
Then  there  is  the  question  of  secondary  gastrotomy,  which  consists  in  -i"^-^  •  • 
operating  after  the  death  of  the  foetus  when  urgent  symptoms  have  A^svsXU^ 
arisen — a  course  which  is  advocated  by  Mr.  Hutcliinson.  In  favor  of  I 
this  procedure  it  is  urged  that  by  delay  the  inflammation  taking  place 
about  the  cyst  will  have  greatly  increased  the  chance  of  adhesions  hav- 
ing formed  between  it  and  the  abdominal  parietes,  so  as  to  shut  off  its 
contents  from  the  cavity  of  the  peritoneum.  The  more  effectually  this 
has  been  accomplished,  the  greater  are  the  chances  of  recovery.  When 
the  foetus  has  been  dead  for  some  time,  the  vascularity  of  the  cyst  will 
also  be  lessened,  and  the  placental  circulation  will  have  ceased,  so  that 
the  danger  of  hemorrliage  will  be  much  diminished. 

It  will  be  seen,  tlierefore,  that  there  are  arguments  in  favor  of  each 
of  these  views.  The  results  of  the  primary  operation  are  far  less  favor- 
able than  we  should  have,  a  priori,  supposed.  Since  the  first  edition  of 
this  Nvork  appeared  the  subject  lias  been  carefully  studied  by  Dr.  Parry 
in  liis  exhaustive  treatise  on  Extra-uterine  Fcetation.  lie  has  there 
shown  lliat  when  the  (-ase  is  left  until  nature  has  shown  the  cliannel 
through  whici)  elimination  is  to  be  effected,  the  mortality  is  17..'>")  ])er 
cent,  less  than  in  the  cases  in  wliicli  the  primary  operation  was  jjcrformed. 
ITis  conclusion  is  that ''  the  j)rimary  operation  caimot  be  too  forcibly  con- 


188  PREGNANCY. 

dcnmcd.  It  is  not  too  much  to  say  that  this  operation  adds  only  another 
danger  to  a  life  already  trembling  in  the  balance,  which  the  delusive 
hope  of  saving  the  uncertain  life  of  a  child  does  not  warrant  us  in  assum- 
ing." It  is  only  just  to  remember,  as  is  forcibly  pointed  out  by  Keller, 
that  in  these  days  of  advanced  abdominal  surgery  a  better  result  might 
be  anticipated  than  when  gastrotomy  was  performed  in  the  haphazard 
way  wdiich  was  usual  before  we  had  gained  experience  from  ovariotomy. 
No  doubt  minute  care  in  the  performance  of  the  operati(jn,  a  due  atten- 
tion to  its  details,  studiously  avoiding  as  much  as  possible  the  passage  of 
blood  and  the  contents  of  the  cyst  into  the  peritoneal  cavity,  and  a  free 
use  of  antiseptics,  would  materially  lessen  its  peril.  This  conclusion  is 
well  illustrated  in  a  recent  interesting  paper  by  Thomas,  who  relates 
three  successful  cases  of  laparotomy  in  abdominal  pregnancy.^ 

Mode  of  Performing  the  Operation. — The  operation,  then,  should  be 
performed  with  all  the  precautions  with  which  we  surround  ovariotomy. 
The  incision,  best  made  in  the  linea  alba,  should  not  be  greater  than  is 
necessary  to  extract  the  foetus,  and  may  be  lengthened  as  occasion  requires. 
It  has  been  suggested  that  should  the  head  be  felt  presenting  above  the 
vagina,  the  intervening  structures  should  be  divided  and  the  foetus  with- 
drawn by  the  forceps.  This  procedure  was  actually  adopted  with  success 
in  1816  by  Dr.  John  King  of  Edisto  Island,  South  Carolina.  If  there 
are  no  adhesions,  the  ^^'alls  of  the  cyst  should  be  stitched  to  the  margin 
of  the  incision,  so  as  to  shut  it  off  as  completely  as  possible  from  the 
peritoneal  cavity.  This  has  been  specially  insisted  on  by  Braxton  Hicks, 
and  should  never  be  omitted.  The  special  risk  is  not  so  much  the 
wounding  of  the  peritoneum  as  the  subsequent  entrance  of  septic  matter 
from  the  cyst  into  its  cavity.  Another  cardinal  rule,  both  in  primary 
and  secondary  gastrotomy,  is  to  make  no  attempt  to  remove  the  jjlacenta. 
Its  attachments  are  generally  so  deep-seated  and  diffused  that  any  endeav- 
or to  separate  it  is  likely  to  be  attended  ^\\i\\  profuse  and  uncontrollable 
hemorrhage  or  with  serious  injury  to  the  structure  to  which  it  is  attached. 
Many  of  the  failures  after  operating  can  be  traced  to  a  neglect  of  this 
rule.  The  best  subsequent  course  to  pursue,  after  removing  the  foetus 
and  arresting  all  hemorrhage  either  by  ligature  or  the  actual  cautery,  is 
to  sponge  out  the  cyst  as  gently  as  possible,  sprinkle  the  cavity  with 
iodoform  or  with  equal  parts  of  tannin  and  salicylic  acid,  as  recom- 
mended by  Freund,^  and  then  to  bring  the  upper  part  of  the  wound  into 
apposition  with  sutures,  leaving  the  lower  open,  ^vith  the  cord  protrud- 
ing, so  as  to  ensure  an  outlet  for  the  escape  of  the  placenta  as  it  slips 
down.  The  subsequent  treatment  must  be  specially  directed  to  favor 
the  escape  of  the  discharge  and  to  prevent  the  risk  of  septicsemia.  These 
objects  may  be  much  aided  by  injections  of  antiseptic  fluids,  such  as 
solution  of  carbolic  acid  or  diluted  Condy's  fluid ;  and  it  would  proba- 
bly be  advisable  to  place  a  drainage-tube  in  the  lower  augle  of  the 
wound.  It  may  be  well  to  point  out  that  there  is  no  operation  in  which 
a  scrupulous  following  of  the  antiseptic  method  on  Sir  Joseph  Lister's 
principles  is  so  likely  to  be  useful. 

As  long  as  the  placenta  is  retained  the  danger  is  necessarily  great,  and 

^  Am.  Jonrn.  of  Med.  Sci.,  .Jan.,  1879. 
2  Eclin.  Med.  Jonrn.,  Dec,  1883. 


ABNORMAL  PREGNANCY.  189 

it  may  be  many  days,  or  even  weeks,  before  it  is  discharged.  When 
once  this  is  effected,  the  sac  may  be  expected  to  contract,  and  eventually 
to  close  entirely. 

\_Relative  Risks  of  Primary  and  Secondary  Laparotomy  in  Abdominal 
Pregnancies. — In  view  of  the  improvements  in  abdominal  surgery, 
especially  in  its  application  to  women,  and  the  disposition  that  exists  to 
undertake  with  little  hesitation  the  performance  of  operations  which  a 
few  years  ago  were  regarded  as  almost  necessarily  fatal,  it  becomes  a 
matter  of  vital  importance  to  consider  whether  we  are  justified  in 
attempting  to  save  the  life  of  a  foetus  coming  to  maturity  in  the  abdom- 
inal cavity  by  the  use  of  the  knife,  either  by  the  past  record  of  such 
operations  or  by  any  reasonable  ground  of  hope  that  the  inherent  diffi- 
culties of  the  condition  may  be  overcome  through  the  advantages  to  be 
derived  from  antiseptics,  abdominal  drainage,  irrigation,  etc. 

A¥e  are  told  by  some  very  prominent  gynagcologists  that  the  statistics  of 
the  past  are  of  little  value  in  this  operation  ;  that  this  is  a  progressive  age 
in  abdominal  surgery ;  and  that  with  the  dimunition  of  risks  under  Lister- 
ism  we  ought  to  be  able  to  do  better  than  in  the  past,  and  to  overcome  the 
dangers  and  difficulties  arising  from  the  vascularity  of  the  cyst  wall,  the 
activity  of  the  placental  circulation,  the  decomposition  and  exfoliation 
of  the  placenta,  with  its  accompanying  hemorrhage  or  septic  poisoning, 
and  the  presence  of  puriform  fluid  in  the  cyst  or  abdominal  cavity.  It 
is  certainly  very  tempting  to  operate  in  the  interest  of  two  lives,  and  it 
is  true  that  by  postponement  we  run  a  risk  of  the  patient  being  lost 
before  a  time  considered  safer  for  operating  may  arrive.  This  is  a  deli- 
cate question  to  settle,  and  one  which  will  be  appreciated  by  some  of  my 
contemporaries  who  have  had  this  unfortunate  experience  and  regretted 
afterward  that  they  had  not  operated  early.  But  what  is  the  record  of 
the  past  ?  Has  not  antiseptic  surgery  had  a  trial  yet  ?  When  asked  what 
has  been  the  mortality  under  the  primary  operation,  a  gynsecologist 
will  generally  refer  the  applicant  to  the  work  of  Dr.  Parry,  already 
referred  to,  and  in  it  he  finds  a  table  of  20  cases  of  so-called  primary 
laparotomies  ^'■performed  during  or  at  the  end  of  gestation ^''^  and  that  6 
of  these  are  stated  as  having  saved  the  women,  with  two  of  their  children. 
This  record,  if  reliable,  would  give  a  recovery  of  30  per  cent. — a  far 
higher  one  than  will  be  presently  shown  from  a  careful  re-examination 
of  his  statistics.  Had  Dr.  Parry  examined  the  monograph  of  Dr.  Keller 
of  Strasbourg,^  he  would  not  have  fallen  into  the  error  I  am  about  to 
point  out,  as  in  this  paper  some  of  his  primary  cases  are  in  the  sec- 
ondary list. 

My  attention  having  been  directed  to  some  errors  in  Dr.  Parry's  sta- 
tistics, I  was  led  to  re-examine  his  sources  of  information,  and  am  sur- 
prised to  find  that  not  one  of  his  six  recoveries  under  primary  lapar- 
otomy, so  called,  was  entitled  to  be  thus  designated. 

Chse  f)  was  operated  upon  by  Dr.  Schreyer  of  Hamburg  in  1837,  and 
reported  in   Casper's  WocJmiscJiriff,  No.  xlv.,  1837,  ]mge  726. 

Ch^e  6,  credited  to  "Scliwanck"  ((!orrectly  Zvvanck),  is  the  same  as 
Case  5,  and  was  tak(in  from  a  sh(jrt  abstract  report  in  the  Archiv.  gen.  de 
Med.,  June,  1838,  p.  227,  giving  the  operation  to  Dr.  Zwanck,  who  was 

[' 7>»  GroHxenseH  Ej:lru-u(Kr!.nrs,Va,nH,  1872.] 


190  PREGNANCY. 

the  assistant  and  reporter.  The  (lescrij)tion  of  the  operation  shows  elearly 
that  the  frctus  was  taken  out  of  some  form  of  uterine  cavity,  from  wliich 
the  placenta  was  readily  removed,  and  that  the  woman  recovered  in  three 
weeks.  Prof.  Litzmann  of  Kiel,  Germany,  believes  that  the  foetus  was 
removed  from  ''  a  very  thin-walled  uterus." 

Case  9.  Dr.  Decouene  of  Courtrai,  France,  performed  the  Caesarean 
operation  six  times  in  ten  years  (1841-51),  and  saved  five  women  and 
four  children.  Dr.  Parry's  reference  is  incorrect,  but  these  six  cases  are 
in  the  volume  named. ^  Prof.  Litzmann  says  that  the  case  (9)  was  a  twin 
pregnancy,  in  which  laparotomy  was  performed  after  uterine  rupture. 

Case  10,  Dr.  Frederick  A.  Stutter's.  Pregnancy  had  existed  45  weeks, 
and  the  foetus,  which  had  been  dead  five  weeks,  was  already  in  a  putrid 
state.  The  decomposition  hastened  the  separation  of  the  placenta,  which 
was  removed  entire  in  five  days. 

Case  11,  Drs.  Ramsbotham  and  Adams's.  Here  the  foetus  died  just 
before  full  maturity,  and  the  operation  was  postponed  for  safety  for  six 
months.  The  woman  was  then  delivered  by  secondary  laparotomy,  and 
recovered  :   she  was  pregnant  for  15  months. 

Case  14.,  Dr.  AVilliam  D.  Hooper's  of  Liberty,  Virginia.  Dr.  Parry 
gives  the  duration  of  pregnancy  as  "  223  days."  Having  carefully  read 
the  original  record,  I  am  inclined  to  believe  that  the  foetus  was  carried 
more  than  five  years.  The  woman,  a  two-para,  was  married  a  second 
time  when  in  good  health.  This  soon  began  to  fail  under  some  abdomi- 
nal malady,  but  she  menstruated  regularly  from  April  1,  1866,  to  June, 
1871,  with  one  exception  in  the  latter  year,  and  did  not  suppose  herself 
pregnant.  Her  health  began  decidedly  to  fail  in  January,  1871,  and 
she  was  a  confirmed  invalid  until  ojDcrated  upon  on  October  24,  1871. 
She  had  passed  foetal  bones  from  her  rectum  four  months  before,  and  her 
abdomen  was  about  to  open  spontaneously  when  she  was  relieved  by  the 
knife,  and  a  putrid  foetus  removed  without  opening  the  peritoneal  cavity. 
The  foetus  Mas  mainly  a  skeleton,  and  was  computed  as  one  of  at  least 
seven  months. 

In  contrast  with  Dr.  Parry's  record.  Prof.  Litzmann  ^  gives  one  of  10 
genuine  primary  operations.  The  children  Mere  all  living,  and  were 
delivered  alive.  The  M'omen  M'ere  pregnant  for  periods  ranging  from  29 
M-eeks  to  full  maturity.  Nine  of  the  women  died — five  on  the  first  day, 
two  on  the  second,  one  on  the  third,  and  one  on  the  sixteenth.  Tm'O 
fully-matured  children  lived  and  thrived  ;  a  third  died  in  three  months, 
and  a  fourth  on  the  second  day.  The  remaining  six  lived  from  a  few 
hours  to  fifty. 

The  only  surviving  woman  M'as  the  patient  of  ISIr.  Jessop  of  Leeds, 
England,  operated  upon  in  1875.  This  case,  thus  far,  of  all  the  lapar- 
otomies undertaken  in  the  hope  of  saving  tM'o  lives,  is  the  only  one 
knoMii  to  me  that  has  not  been  a  failure  so  far  as  the  mother  was  con- 
cerned ;  and  in  this  instance  the  condition  of  the  M'oman  for  a  long  time 
gave  very  little  encouragement  of  final  recovery,  and  her  child  was  lost 
at  eleven  months  with  croup  and  pneumonia.    A  perusal  of  Mr.  Jessop's 

P  Giizette,  cJes  Hopitavx,  Paris,  1852,  p.  221.] 

[^  Zur  Feslalellmig  der  Indicatinnen  filr  die  Gasirotomie  bei  Schivangerschaft  ausserhalb  der 
Geburmrdter,  von  C.  Litzmann,  8vo,  pp.  79.] 


ABNORMAL  PREGNANCY.  191 

experience  with  his  patient  will  certainly  not  encourage  one  to  try  a 
similar  experiment.^ 

After  an  extra-uterine  foetus  is  dead  within  the  abdominal  cavity,  the 
risk  of  its  removal,  provided  time  enough  shall  have  passed  for  the 
requisite  anatomical  changes  to  take  place,  is  very  materially  diminished, 
as  shown  by  a  number  of  operations  in  this  country  and  in  Europe  per- 
formed within  a  few  years.  If  the  woman  survives  the  immediate  risk 
of  the  false  labor  that  usually  takes  place  when  the  fatus  nears  maturity, 
she  usually  improves  somewhat  in  health  for  a  time,  by  reason  of  the 
removal  of  pressure  produced  by  the  absorption  of  much  of  the  liquor 
amnii.  The  death  of  the  foetus  rendering  the  placenta  no  longer  of  any 
functional  importance,  this  element  of  danger  in  the  primary  operation 
ceases  in  time  to  be  such,  by  reason  of  changes  in  its  structure  which  fit 
it  for  undergoing  exfoliation  without  the  hemorrhage  which  follows  the 
primary  operation.  The  question,  then,  of  operating  becomes  one  of 
time,  which  itself  has  no  special  limit,  as  the  changes  in  the  placental 
circulation  that  follow  foetal  death  may  be  slow  or  rapid  according  to 
circumstances;  but  experience  teaches  that  from  10  to  12  weeks  will  be 
sufficient.  Much  less  than  this  will  be  required  where  decomposition  has 
commenced ;  and  in  that  event  an  earlier  operation  ]iiay  be  demanded 
on  account  of  the  failing  health  of  the  woman.  Case  10,  already  noted, 
was  an  example  of  this,  the  foetus  having  been  dead  only  five  weeks.  In 
one  case  in  which  I  was  consulted  a  decomposing  foetus  was  removed 
when  four  months  dead,  but  for  some  Aveeks  the  patient  had  been  suffer- 
ing from  a  slow  blood-poisoning,  with  pulse  105,  and  attacks  of  mental 
distress  and  nervous  excitement  at  night :  this  woman  is  now  in  excel- 
lent health.  It  is  not  necessary  here  to  defend  the  secondary  operation 
or  to  collect  its  statistics  in  proof  of  its  comparative  safety  in  skilful 
hands,  as  abundant  evidence  of  this  is  shown  in  the  reports  of  cases  in 
medical  journals.  Antiseptic  surgery,  drainage,  and  irrigation  here  avail, 
as  the  placenta,  if  left  intact,  will  usually  come  away  without  hemor- 
rhage. Dr.  Parry  condemned  the  primary  ojaeration  in  strong  terms, 
although  his  statistics  gave  a  measure  of  hope  for  its  success.  Later  in 
life  he  lost  a  primary  case  by  delay,  and  regretted  not  having  operated ; 
but  he  need  not  have  done  so,  except  for  the  possibility  of  saving  the 
foetus,  and  it  might  be  then  for  a  few  days  only. — Ed.] 

Treatment  ichen  the  Foetus  is  Dead. — When  the  foetus  is  dead,  or  when 
we  have  determined  not  to  attempt  primary  gastrotomy,  it  is  advisable 
to  wait,  very  carefully  watching  the  patient,  until  either  the  gravity  of 
her  general  symptoms  or  some  positive  indication  of  the  channel  through 
which  nature  is  about  to  atteni]:>t  to  eliminate  the  fetus  shows  us  that  the 
time  for  action  has  arrived.  If  there  be  distinct  bulging  of  the  cyst  in 
the  vagina  or  in  the  retro-vaginal  cul-de-sac,  especially  if  an  opening  has 
formed  there,  we  may  properly  content  ourselves  with  aiding  the  passage 
of  the  fijctus  through  the  channcjl  thus  iudicated,  and  removing  the  parts 
that  present  piecemeal  as  they  come  within  reach,  cautiously  enlargiug 
the  apcTture  if  necessary.  If  the  sac  have  ojieued  into  the  intestines,  the 
expulsion  of  tlu;  fa'tus  through  this  channel  is  s(j  tedious  and  difficult, 

['  \)r.  Wcrtli  of  Kiel  staled  before  tlie  Tnt.  Med.  Congress  of  1884  that  lie  h;ul  colleeted 
the  records  of    17  operations,  witli   two   recoveries.] 


192  PREGNANCY. 

the  exhaustion  attending  it  so  likely  to  prove  fatal,  and  the  danger  from 
decomposition  of  the  foetus  through  passage  of  intestinal  gas  so  great, 
that  it  would  probably  be  best  to  attempt  to  rcuKne  it  by  gastrotomy, 
especially  if  it  is  only  recently  dead  and  tlie  greater  portion  is  still 
retained. 

Mode  of  Performing  Secondary  Gastrotomy. — If  an  opening  forms  at 
the  abdominal  parietes,  or  if  the  symptoms  determine  us  to  resort  to 
secondary  gastrotomy  before  this  occurs,  the  operation  must  be  per- 
formed in  the  same  way  and  with  the  same  precautions  as  })rimary  gas- 
trotomy. Here,  as  before,  the  safety  of  the  operation  must  greatly 
depend  on  the  amount  and  firmness  of  the  adhesions,  for  if  the  cyst  be 
not  completely  shut  off  from  the  peritoneal  cavity  the  risks  of  the  opera- 
tion will  be  little  less  than  those  of  primary  gastrotomy.  It  would 
obviously  materially  influence  our  decision  and  prognosis  if  we  could 
determine  this  point  before  operating.  Unfortunately,  it  is  impossible, 
as  the  experience  of  ovariotomists  proves,  to  ascertain  the  existence  of 
adhesions  with  any  certainty.  If,  however,  we  find  that  the  abdominal 
parietes  do  not  move  freely  over  the  cyst,  and  if  the  umbilicus  be 
depressed  and  immovable,  the  presumption  is  that  considerable  adhe- 
sions exist.  If  they  are  found  not  to  be  present,  the  cyst  walls  should 
be  stitched  to  the  margin  of  the  incision,  in  the  manner  already  indi- 
cated, before  the  contents  are  removed. 

If  the  foetus  has  been  long  dead  and  its  tissues  greatly  altered,  its 
removal  may  be  a  matter  of  difficulty.  In  the  case  under  my  own  care, 
already  alluded  to,  the  foetal  structures  formed  a  sticky  mass  of  such  a 
nature  that  I  believe  it  would  have  been  impossible  to  empty  the  cyst 
had  an  operation  been  attempted.  This  would  be,  to  some  extent,  a 
further  argument  in  favor  of  the  primary  operation. 

Oldening  of  Cyst  by  Caustics. — The  importance  of  adhesions  has  led 
some  practitioners  to  recommend  the  opening  of  the  cyst  by  potassa  fusa 
or  some  other  caustic,  in  the  hope  that  it  would  set  up  adhesive  inflam- 
mation around  the  aperture  thus  formed.  Several  successful  operations 
by  this  method  are  recorded,  and  it  would  be  worth  trying  should  the 
extreme  mobility  of  the  cyst  lead  us  to  suspect  that  no  adhesions 
existed.  If  we  have  to  deal  with  a  case  in  which  fistulous  openings 
leading  to  the  cyst  have  already  formed,  it  may,  perhaps,  be  advisable 
to  dilate  the  apertures  already  existing,  rather  than  make  a  fresh 
incision  ;  but  in  determining  this  point  the  surgeon  will  naturally  be 
guided  by  the  nature  of  the  case  and  the  character  and  direction  of  the 
fistulous  openings. 

General  Treatment. — It  is  almost  needless  to  say  anything  of  general 
treatment  in  these  trying  cases,  but  the  administration  of  opiates  to  allay 
the  sufferings  of  the  patient,  and  the  endeavor  to  support  the  severely- 
taxed  vital  energies  by  appropriate  food  and  medication,  will  form  a 
most  important  part  of  the  management,  Freund  specially  insists  on 
the  importance  of  careful  regulation  of  the  bowels,  and  on  making  milk 
the  staple  article  of  diet,  as  important  points  in  the  management  of  cases 
prior  to  operation. 

Gestation  in  a  Bilohed  Uterus. — A  few  words  may  be  said  as  to 
gestation  in  the  rudimentary  horn  of  a  bilobed  uterus,  to  which  con- 


ABNORMAL  PREGNANCY.  193 

siderable  attention  has  of  late  years  been  directed  by  the  writings  of 
Kussmaul  and  others.  It  appears  certain  that  many  cases  of  supposed 
tubal  gestation  are  really  to  be  referred  to  this  category.  Although 
such  cases  are  of  interest  pathologically,  they  scarcely  require  much  dis- 
cussion from  a  practical  point  of  view,  inasmuch  as  their  history  is 
pretty  nearly  identical  with  that  of  tubal  pregnancy.  The  rudimentary  1 
horn  is  distended  by  the  enlarging  ovum,  and  after  a  time,  when  further  ] 
distension  is  impossible,  laceration  takes  place.  As  a  matter  of  fact,  all  ' 
the  thirteen  cases  collected  by  Kussmaul  terminated  in  this  way ;  and 
even  on  post-mortem  examination  it  is  often  extremely  difficult  to  dis- 
tinguish them  from  tubal  pregnancies.  The  best  way  of  doing  so  is 
probably  by  observing  the  relations  of  the  round  ligaments  to  the 
tumor,  for  if  the  gestation  be  tubal  they  will  be  found  attached  to  the 
uterus  on  the  inner  or  uterine  side  of  the  cyst,  whereas  if  the  pregnancy 
be  in  a  rudimentary  horn  of  the  uterus  they  will  be  pushed  outward 
and  be  external  to  the  sac.  In  the  latter  case,  moreover,  the  sac  will 
be  probably  found  to  contain  a  true  decidua,  which  is  not  the  case  in 
tubal  pregnancy.  The  only  point  in  which  they  diifer  is  that  in  cor- 
nual  pregnancy  rupture  may  be  delayed  to  a  somewhat  later  period 
than  in  tubal,  on  account  of  the  greater  distensibility  of  the  supple- 
mentary horn. 

Missed  Labo)'. — The  term  "missed  labor ^^  is  applied  to  an  exceed- 
ingly rare  class  of  cases  in  which,  at  the  full  period  of  pregnancy,  labor 
has  either  not  come  on  at  all,  or,  having  commenced,  the  pains  have 
subsequently  passed  oif,  and  the  foetus  is  retained  in  utero  for  a  very  | 
considerable  length  of  time.  Under  such  circumstances  it  has  usually  ^ 
happened  that  the  membranes  have  ruptured  at  or  about  the  proper 
term,  and  the  access  of  air  to  the  foetus  in  utero  has  been  followed  by 
decomposition.  A  putrid  and  offensive  discharge  has  then  commenced, 
and  eventually  portions  of  the  disintegrating  foetus  have  been  expelled 
per  vaginam.  This  discharge  may  go  on  until  the  entire  foetus  is  grad- 
ually thrown  off,  or,  more  frequently,  the  patient  dies  from  septicaemia 
or  other  secondary  result  of  the  presence  of  the  decomposing  mass  in 
utero.  Thus,  McClintock  relates  one  case  ^  in  which  symptoms  of  labor 
came  on  in  a  woman,  45  years  of  age,  at  the  expected  period  of  delivery, 
but  passed  off  without  the  expulsion  of  the  foetus.  For  a  period  of 
sixty-seven  weeks  a  highly  offensive  discharge  came  away,  with  some 
few  bones,  and  she  eventually  died  with  symptoms  of  pysemia.  He  also 
cites  another  case  in  which  the  patient  died  in  the  same  way  after  the 
fjetus  had  been  retained  for  eleven  years. 

Ulceration  of  the  Uterine  Walls  sometimes  Occurs. — Sometimes,  when 
the  foetus  has  been  retained  for  a  length  of  time,  a  further  source  of 
danger  has  been  added  by  ulceration  or  destruction  of  the  uterine  walls, 
prol)ably  in  consequence  of  an  ineffectual  attempt  at  its  elimination. 
This  occurred  in  Dr.  Oldham's  case  (Fig.  80),  in  whicli  the  contained " 
mass  is  said  to  have  nearly  worn  through  the  anterior  wall  of  the  uterus ; 
and  also  in  one  reported  ])y  Sir  James  Sim[)son,^  in  which  a  patient  died 
three  montlis  after  term,  the  fjctus  having  undergone  fatty  metamor- 
phosis, an  opening  i\ni  size  of  half  a  crown  having  formed  between  the 

^  Dublin  Quart.  Journ.,  Feb.  and  May,  1864.  '■'  Edin.  Med.  Joiirn.,  1805. 

13 


194 


PREGNANCY. 


transverse  colon  and  the  uterine  cavity.     It  is  also  stated  that  "the 
uterine  walls  were  as  thin  as  parchment." 

In  some  few  cases,  however,  probably  when  the  entrance  of  air  has 
been  prevented,  the  foetus  has  been  retained  for  a  leng;th  of  time  with- 
out decomposing  and  without  giving  rise  to  any  troublesome  symptoms. 


Fig.  86. 


Contents  of  the  Cyst  in  Dr.  Oldham's  Case  of  Missed  Labor. 

Such  a  case  is  reported  by  Dr.  Cheston,^  in  which  the  foetus  remained  in 
utero  for  fifty-two  years. 

Its  Causes  are  not  Properly  Understood. — The  causes  of  this  strange 
occurrence  are  altogether  unknown.  Generally,  the  foetus  seems  to  have 
died  some  time  before  the  proper  term  for  labor,  and  this  may  have  influ- 
enced the  character  of  the  pains.  It  is  probably  also  most  apt  to  occur 
in  women  of  feeble  and  inert  habit  of  body,  possibly  where  there  was 
some  obstacle  to  the  dilatation  of  the  cervix  which  the  pains  were 
unable  to  overcome.  Barnes  suggests^  that  some  presumed  examples 
of  missed  labor  "  were  really  cases  of  interstitial  gestation,  or  gestation 
in  one  horn  of  a  two-horned  uterus."  In  several  of  the  cases,  however, 
the  details  of  the  post-mortem  examination  are  too  minute  to  admit  of  the 
possibility  of  mistake  having  been  made. 

Sometimes  Confounded  ivith  Extra-utei'ine  Foetation. — Miiller  of  Nancy 
has  recently  attempted  to  prove,  by  a  critical  examination  of  published 
cases,  that  most  examples  of  so-called  "  missed  labor  "  were  in  reality 
cases  of  extra-uterine  foetation,  in  which  an  ineffectual  attempt  at  par- 
turition took  place,  the  foetus  being  subsequently  retained. 

Its  Dangers  are  Serious. — From  what  has  been  said,  it  will  be  seen 


1  Med.-Chir.  Trans.,  1814. 


Diseases  of  Women,  p.  445. 


ABNORMAL  PREGNANCY.  195 

that  the  clangers  arising  from  this  state  are  very  considerable,  and  when 
once  the  full  term  has  passed  beyond  doubt,  especially  if  the  presence  of 
an  oflPensive  discharge  shows  that  decomposition  of  the  foetus  has  com- 
menced, it  would  be  proper  practice  to  empty  the  uterus  as  soon  as  pos- 
sible. The  necessary  precaution,  however,  is  not  to  decide  too  quickly 
that  the  term  has  really  passed ;  and  therefore  we  must  either  allow  suf- 
ficient time  to  elapse  to  make  it  quite  certain  that  the  case  really  falls 
under  this  category  or  have  unequivocal  signs  of  the  death  of  the  foetus 
and  injury  to  the  mother's  health.  If  we  had  to  deal  with  the  case 
before  any  extensive  decomposition  of  the  foetus  had  occurred,  we  prob.a- 
bly  should  find  little  difficulty  in  its  management,  for  the  proper  course 
then  would  be  to  dilate  the  cervix  with  fluid  dilators  and  remove  the 
foetus  by  turning ;  or,  before  doing  so,  we  might  endeavor  to  excite 
uterine  action  by  pressure  and  ergot.  If  the  case  did  not  come  under 
observation  until  disintegration  of  the  foetus  had  begun,  it  would  be 
more  difficult  to  deal  with.  If  the  foetus  had  become  so  much  broken 
up  that  it  was  being  discharged  in  pieces.  Dr.  McClintock  says  that  "  in 
regard  to  treatment  our  measures  should  consist  mainly  of  palliatives — 
viz.  rest  and  hip-baths,  to  subdue  uterine  irritation  ;  vaginal  injections, 
to  secure  cleanliness  and  .prevent  excoriation ;  occasional  digital  exam- 
ination, so  as  to  detect  any  fragments  of  bone  that  might  be  presenting 
at  the  OS  and  to  assist  in  removing  them.  These  are  plain  rational 
measures,  and  beyond  them  we  shall  scarcely,  perhaps,  be  justified  in 
venturing.  Nevertheless,  under  certain  circumstances,  I  would  not 
hesitate  to  dilate  the  cervical  canal  so  as  to  permit  of  examining  the 
interior  of  the  womb  and  of  extracting  any  fragments  of  bone  that  may 
be  easily  accessible ;  but  unless  they  could  thus  be  easily  reached  and 
removed,  the  safer  course  would  be  to  defer,  for  the  present,  interfering 
with  them."  ^ 

It  may  be  doubted,  I  think,  whether,  considering  the  serious  results 
which  are  known  to  have  followed  so  many  cases,  it  would  not,  on  the 
whole,  be  safer  to  make  at  least  one  decided  effort,  under  chloroform,  to 
remove  as  much  as  possible  of  the  putrefying  uterine  contents  after  the 
OS  has  been  fully  dilated.  Such  a  procedure  would  be  less  irritating 
than  frequently-repeated  endeavors  to  pick  away  detached  portions  of 
the  foetus  as  they  present  at  the  os  uteri.  When  once  the  os  is  dilated, 
antiseptic  intra-uterine  injections,  as  of  diluted  Condy's  fluid,  might 
safely  and  advantageously  be  used.  Unquestionably,  it  would  be  better 
practice  to  interfere  and  empty  the  uterus  as  soon  as  we  are  quite  satis- 
Hed  of  the  nature  of  the  case,  rather  than  to  delay  until  the  foetus  has 
been  disintegrated. 

[Fn^m  several  cases  of  "  missed  labor  "  that  have  been  reported  in  the 
United  States  we  find  that  the  failure  of  the  uterus  to  expel  its  contents 
may  Ije  due  to  a  variety  of  causes.  If  we  are  certain  that  the  foetus  is 
actually  in  utero,  that  there  is  no  pelvic  or  vaginal  obstruction,  and  that 
the  uterus  is  itself  of  normal  form,  then  wc  must  look  fi)r  the  cause  of 
diffi(;ulty  in  the  organ  itself.  By  an  examination  of  our  reports  of 
Ctesarean  operations  we  find  that  there  have  been  several  cases  in  which 
the  power  of  the  uterine  contractions  was  insufficient  to  overcome  the 

^  Dublin  Qnnrt.  Journ.,  vol.  xxxvii.  p.  314. 


196  PREGNANCY. 

resistance  to  expansion  in  the  cervix.  This  may  be  due  either  to  a  want 
of  contractile  force  in  the  muscular  coat,  to  a  change  in  the  tissues  of  the 
cervix  as  the  result  of  inflammation,  or  to  both  conditions  combined. 
Where  the  muscular  power  of  the  uterus  is  in  its  integrity,  the  resistance 
in  the  cervix  may  be  such  that  the  os  may  remain  unchanged  after  it  is 
slightly  opened,  and  the  j)atient  continue  in  labor  until  the  contractile 
power  of  the  uterus  is  exhausted,  when  all  muscular  contraction  will 
cease.  Efforts  at  expulsion  may  recur  at  intervals  covering  a  period  of 
many  months,  w^hen  they  will  cease  finally.  In  two  Csesarean  cases  in 
the  United  States,  the  subjects  being  black,  there  was  found  a  calcareous 
incrustation  over  and  around  the  internal  os  uteri.  The  first  operation 
was  performed  in  Virginia  in  1828  upon  a  multipara  of  25.^  She  was 
taken  in  labor  at  term,  and  had  pains  for  two  or  three  days  together,  at 
intervals,  for  about  four  wrecks,  after  which  pains  returned  occasionally 
during  fifteen  months.  The  cervix  admitted  the  index  finger,  and  in 
time  the  foetus  became  putrid.  When  operated  upon  she  had  carried 
the  foetus  two  years.  There  was  very  little  hemorrhage  in  the  opera- 
tion, although  the  uterus  failed  to  contract,  and  for  this  reason  was 
sutured.  The  woman  died  in  the  second  week,  of  peritonitis,  following 
an  attack  of  indigestion  produced  by  a  meal  of  animal  food  and  cider. 
The  second  case,  also  a  multipara,  was  operated  upon  in  Georgia  in 
1877,  after  a  labor  of  four  days,  by  Dr.  Theodore  Starbuck,  who 
describes  the  deposit  as  "  ossific."  The  child  was  dead,  and  the  woman 
died  of  internal  hemorrhage  very  suddenly  on  the  third  day.^ 

In  a  third  case,  also  black,  the  cause  of  retention  appears  to  have  been 
a  prevention  of  the  descent  of  the  foetus,  from  its  arm  and  leg  being 
secured  within  the  uterus.  The  woman  was  33  years  old  and  the 
mother  of  one  child,  and  was  operated  upon  by  Dr.  J.  C.  Egan  of 
Shreveport,  Louisiana,  August  25,  1860.^  On  May  4,  1857,  while  at 
work  in  the  field,  she  felt  a  sudden  and  violent  pain  in  the  left  side ; 
fainted,  remained  insensible  so  long  as  to  be  thought  dead,  but  finally 
revived,  and  was  pronounced  four  months  pregnant.  Labor  began  in 
November ;  the  os  dilated,  head  presented,  but  did  not  descend  ;  pains 
continued  at  intervals  for  a  month.  In  the  fall  of  1858  an  abscess 
opened,  leaving  a  fistula  1\  inches  below  the  umbilicus.  When  operated 
upon  nearly  two  years  later,  she  was  greatly  emaciated  and  affected  wdth 
hectic  fever.  The  uterus  being  adherent,  the  peritoneal  cavity  was  not 
opened.  When  the  foetus  was  extracted,  its  left  foot  and  hand  were 
wanting,  and,  search  being  made,  were  found  in  a  pouch  on  the  left  side 
of  the  uterus,  enclosed  by  bands  which  were  cut  for  their  liberation. 
The  uterus  was  examined  bi-manually  to  make  sure  that  the  cervix  was 
sufficiently  open  for  drainage.  The  decomposed  foetus  had  been  carried 
33  months  after  maturity.  Dr.  Egan  believes  that  a  partial  ruptm-e  of 
the  uterus  took  place  at  the  time  of  her  attack  in  the  field,  and  that  the 
arm  and  leg  were  caught  in  its  partial  cicatrization.  The  woman  made 
a  good  recovery. 

\}  Am.  Jonrn.  Med.  Sci.,  vol.  xviii.  p.  257.] 

[-  Communicated  by  the  operator,  1880.] 

[^  N.  0.  Med.  and  Surg.  Journ.,  Julv,  1877,  p.  35 ;  also  communicated  by  operator, 

1878.] 


ABNORMAL  PREGNANCY.  197 

Much  light  is  thrown  upon  a  possible  way  of  accounting  for  some  of 
the  mysterious  cases  of  missed  labor,  which  have  been  claimed  to  be 
extra-uterine  in  order  to  account  for  them,  by  a  case  recently  operated 
upon  in  Portland,  Maine,  by  Dr.  Stanley  P.  Warren,  and  kindly 
reported  to  me  by  letter.  The  woman  was  a  native,  of  Scotch-Irish 
descent,  aged  32,  and  mother  of  a  child  of  13.  She  last  menstruated  in 
January,  1884.  Supposed  accidental  abortion  in  May,  as  there  was 
hemorrhage;  the  physician  said  he  had  removed  the  placenta,  and  there 
was  a  thick  "molasses-like"  discharge  afterward.  Dr.  Warren  was 
called  in  a  week  later ;  found  metro-peritonitis  and  a  tumor  of  about 
four  inches  in  diameter  in  the  right  groin.  The  peritonitis  became  gen- 
eral, and  Dr.  W.  was  in  attendance  for  15  days.  On  July  1st  the 
tumor  was  in  the  median  line,  and  foetal  movements  and  heart-sounds 
distinct.  Labor  expected  about  October  28th;  subsequent  gestation 
normal.  Was  called  October  28th,  at  11  p.  M, ;  found  no  true  pains ; 
pain  apparently  abdominal,  rather  than  uterine,  and  continuous  in  the 
back  and  over  the  sides  of  the  uterus.  Foetus  transverse,  with  head  to 
right ;  pulse  1 52.  No  change  for  several  days.  Second  week  in 
November  found  child  dead.  Next  four  weeks  slight  occasional  chills, 
and  temperature  102°  for  two  or  three  nights,  but  usually  normal. 
Absolutely  no  expulsive  pains.  Cervix  reached  with  difficulty,  and  fin- 
ger passed  through  a  long  tubular  neck,  but  foetus  not  reached.  Cervix 
absolutely  closed  from  December  21st  to  29th  ;  pulse  120,  temperature 
100°  to  102°.  Attempted  to  dilate  with  sponge  tent,  but  could  not  pass 
it  into  the  uterine  cavity.  December  30th  attempted  to  open  cervix  by 
digital  dilatation,  and  succeeded  finally  in  passing  a  cranioclast,  but  the 
parts  closed  as  soon  as  the  dilators  were  removed.  Patient  in  a  pro- 
found shock.  After  stimulating  for  an  hour  performed  Csesarean  sec- 
tion ;  hemorrhage  slight ;  peritoneum  adherent  everywhere  to  uterus ; 
uterine  wall  ^  inch  thick  ;  child  presented  by  right  arm  and  side ;  pla- 
centa thin  and  far  advanced  in  fatty  degeneration  ;  no  hemorrhage  on  its 
removal ;  uterus  did  not  contract ;  sutured  by  continuous  stitch  with  cat- 
gut. Child  8|-  lbs.  Woman  rallied  slightly,  but  died  of  shock  in  28 
hours.  Drs.  T.  A.  Foster  and  S.  C.  Gordon  were  associated  with  Dr. 
Warren  in  the  management  of  the  case. 

It  would  appear  in  this  instance  of  missed  labor  that  the  changes  pro- 
duced by  metro-peritonitis  prevented  the  natural  dilatation  of  the  cervix 
and  the  contractile  action  of  the  muscular  coat  of  the  uterus.  Possibly, 
fatty  degeneration  of  the  muscular  fibres  had  taken  place,  but  this  could 
not  be  ascertained,  as  tliere  was  no  autopsy. 

The  Cesarean  case  of  Dr.  Brodie  S.  Herndon  of  Fredericksburg,  Vir- 
ginia, operated  upon  with  success  in  1845,  bears  a  close  resemblance  in 
many  of  its  features  to  that  of  Dr.  Warren.  The  subject  was  a  white 
multijiara  of  30,  whose  pains  of  labor  gave  place  to  the  continuous  ])ain 
and  other  cliaractcristic  sym])toms  of  peritonitis.  This  disease  lasted  a 
month,  (hn'ing  whicth  time  the  fluid  contents  of  the  uterus  escaped,  and 
the  vaginal  discharge  became  very  offensive.  Five  weeks  after  the  peri- 
tonitis commenced  the  os  uteri  admitti^d  two  fingers,  and  attempts  at 
dilatation  were  made,  but  failed.  Under  ergot  an  offensive  placenta  was 
expelled,  l)iit  tlie  fa^tus   could   not    be  removed.     The  woman    being 


198  PREGNANCY. 

greatly  wasted  and  her  room  filled  with  stench,  the  Csesarean  operation 
was  performed  on  November  16th,  46  days  after  the  first  signs  of  labor 
appeared.  The  uterus  being  adherent,  the  peritoneal  cavity  was  not 
exposed ;  the  uterus  was  sponged  out,  but  did  not  contract ;  it  was 
closed  in  the  suturing  of  the  abdomen.  The  patient  made  a  good  recov- 
ery. As  in  the  Warren  case,  the  uterus  became  unsuited  for  performing 
the  functions  of  labor  by  reason  of  changes  in  its  tissues  effected  by 
inflammatory  action. — Ed.] 


CHAPTER   yil. 

DISEASES  OF   PREGNANCY. 


Diseases  of  Pregnancy. — The  diseases  of  pregnancy  form  a  subject  so 
extensive  that  they  might  well  of  themselves  furnish  ample  material  for 
a  separate  treatise.  The  pregnant  woman  is  of  course  liable  to  the  same 
diseases  as  the  non-pregnant,  but  it  is  only  necessary  to  allude  to  those 
whose  course  and  effects  are  essentially  modified  by  the  existence  of 
pregnancy,  or  which  have  some  peculiar  effect  on  the  patient  in  conse- 
quence of  her  condition.  There  are,  moreover,  many  disorders  which  can 
be  distinctly  traced  to  the  existence  of  pregnancy.  Some  of  them  are  the 
direct  results  of  the  sympathetic  irritations  which  are  then  so  common- 
ly observed ;  and  of  these  several  are  only  exaggerations  of  irritations 
which  may  be  said  to  be  normal  accompaniments  of  gestation.  These 
functional  derangements  may  be  classed  under  the  head  of  neuroses,  and 
they  are  sometimes  so  slight  as  merely  to  cause  temporary  inconvenience, 
at  others  so  grave  as  seriously  to  imperil  the  life  of  the  patient.  Another 
class  of  disorders  is  to  be  traced  to  local  causes  in  connection  with  the 
gravid  uterus,  and  are  either  the  mechanical  results  of  pressure  or  of 
some  displacement  or  morbid  state  of  the  uterus ;  while  the  origin  of 
others  may  be  said  to  be  complex,  being  partly  due  to  sympathetic  irri- 
tation, partly  to  pressure,  and  partly  to  obscure  nutritive  changes  pro- 
duced by  the  pregnant  state. 

Derangements  of  the  Digestive  System. — Among  the  sympathetic 
derangements  there  are  none  which  are  more  common,  and  none  which 
more  frequently  produce  distress  and  even  danger,  than  those  which 
affect  the  digestive  system.  Under  the  heading  of  "  The  Signs  of  Preg- 
nancy "  the  frequent  occurrence  of  nausea  and  vomiting  has  already 
been  discussed,  and  its  most  probable  causes  considered  (p.  145).  A 
certain  amount  of  nausea  is,  indeed,  so  common  an  accompaniment  of 
pregnancy  that  its  consideration  as  one  of  the  normal  symptoms  of  that 
state  is  fully  justified.  We  need  here  only  discuss  those  cases  in  which 
the  nausea  is  excessive  and  long  continued,  and  leads  to  serious  results 
from  inanition  and  from  the  constant  distress  it  occasions.  Fortunately, 
a  pregnant  woman  may  bear  a  surprising  amount  of  nausea  and  sick- 


DISEASES  OF  PREGNANCY. 


199 


ness  without  constitutional  injury,  so  that  apparently  almost  all  aliments 
may  be  rejected  without  the  nutrition  of  the  body  very  materially  suf- 
fering. At  times  the  vomiting  is  limited  to  the  early  part  of  the  day, 
when  all  food  is  rejected,  and  when  there  is  a  frequent  retching  of  glairy 
transparent  fluid,  in  several  cases  mixed  with  bile,  while  at  the  latter 
part  of  the  day  the  stomach  may  be  able  to  retain  a  sufficient  quantity 
of  food  and  the  nausea  disappears.  In  other  cases  the  nausea  and  vom- 
iting are  almost  incessant.  The  patient  feels  constantly  sick,  and  the 
mere  taste  or  sight  of  food  may  bring  on  excessive  and  painful  vomit- 
ing. The  duration  of  this  distressing  accompaniment  of  pregnancy  is 
also  variable.  Generally  it  commences  between  the  second  and  third 
months,  and  disappears  after  the  woman  has  quickened.  Sometimes, 
however,  it  begins  with  conception,  and  continues  unabated  until  the 
pregnancy  is  over. 

tiymjytopis  of  the  Graver  Cg^es. — In  the  worst  class  of  cases,  when  all 
nourishment  is  rejected  and  when  the  retching  is  continuous  and  painful, 
symptoms  of  very  great  gravity,  which  may  even  prove  fatal,  develop 
themselves.  The  countenance  becomes  haggard  from  suiFering,  the 
tongue  dry  and  coated,  the  epigastrium  tender  on  pressure,  and  a  state 
of  extreme  nervous  irritability,  attended  with  restlessness  and  loss  of 
sleep,  becomes  established.  In  a  still  more  aggravated  degree  there  is 
general  feverishness,  with  a  rapid,  small,  and  thready  pulse.  Extreme 
emaciation  supervenes,  the  result  of  wasting  from  lack  of  nourishment. 
The  breath  is  intensely  fetid  and  the  tongue  dry  and  black.  The  vom- 
ited matters  are  sometimes  mixed  with  blood.  The  patient  becomes  pro- 
foundly exhausted,  a  low  form  of  delirium  ensues,  and  death  may  follow 
if  relief  is  not  obtained. 

Prognosis. — Symptoms  of  such  gravity  are  fortunately  of  extreme 
rarity,  but  they  do  from  time  to  time  arise,  and  cause  much  anxiety. 
Gueniot  collected  118  cases  of  this  form  of  the  disease,  out  of  which  46 
died ;  and  out  of  the  72  that  recovered,  in  42  the  symptoms  only  ceased 
when  abortion,  either  spontaneous  6r  artificially  produced,  had  occurred. 
When  pregnancy  is  over  the  symptoms  occasionally  cease  with  marvel- 
lous rapidity.  The  power  of  retaining  and  assimilating  food  is  rapidly 
regained,  and  all  the  threatening  symptoms  disappear. 

Treatment. — In  the  milder  forms  of  obstinate  vomiting  one  of  the 
first  indications  will  be  to  remedy  any  morbid  state  of  the  primse  vise. 
The  bowels  will  not  unfrequently  be  found  to  be  obstinately  constipated, 
the  tongue  loaded,  and  the  breath  offensive ;  and  when  attention  has  been 
paid  to  the  general  state  of  the  digestive  organs  by  general  aperient 
medicines  and  antacid  remedies,  such  as  bismuth  and  soda  and  liquor 
pepticus  after  meals,  the  tendency  to  vomiting  may  abate  without  fur- 
ther ti'eatmcnt. 

Rer/ulation  of  Diet — The  careful  regulation  of  the  diet  is  very  import- 
ant. Great  benefit  is  oflen  derived  from  recommending  the  patient  not 
to  rise  from  the  recumbent  position  in  the  morning  until  slie  has  taken 
something.  Half  a  cup  of  milk  and  lime-water,  or  a  cup  of  strong 
coffee,  or  a  little  rum  and  milk,  or  cocoa  and  milk,  a  glass  of  s])arkling 
koumiss,  or  even  a  morsel  of  biscuit,  taken  on  waking,  often  has  a 
remarkable  effect  in  diminishing  the  nausea.     When  any  attempt  at 


200  PREGNANCY. 

swallowing  solid  food  brings  on  vomiting,  it  is  better  to  give  up  all  pre- 
tence at  keeping  to  regular  meals,  and  to  order  such  light  and  easily- 
assimilated  food,  at  short  intervals,  as  can  be  retained.  Iced  milk,  with 
lime-  or  soda-water,  given  frequently  and  not  more  than  a  mouthful  at 
a  time,  will  frequently  be  retained  when  nothing  else  will.  Cold  beef- 
jelly,  a  spoonful  at  a  time,  will  also  be  often  kept  down.  Sparkling 
koumiss  has  been  strongly  recommended  as  very  useful  in  such  cases, 
and  is  worthy  of  trial.  It  is  well,  however,  to  bear  in  mind,  in  regulat- 
ing the  diet,  that  the  stomach  is  fanciful  and  capricious,  and  that  the 
patient  may  be  able  to  retain  strange  and  apparently  unlikely  articles 
of  food,  and  that,  if  she  express  a  desire  for  such,  the  experiment  of 
letting  her  have  them  should  certainly  be  tried. 

Medicinal  Treatment. — The  medicines  that  have  been  recommended 
are  innumerable,  and  the  practitioner  will  often  have  to  try  one  after  the 
other  unsuccessfully,  or  may  find,  in  an  individual  case,  that  a  remedy 
will  prove  valuable  which  in  another  may  be  altogether  powerless. 
Amongst  those  most  generally  useful  are  effervescing  draughts  contain- 
ing from  three  to  five  minims  of  dilute  hydrocyanic  acid ;  the  creasote 
mixture  of  the  Pharmacopoeia ;  tincture  of  nux  vomica,  in  doses  of  five 
or  ten  minims ;  single  minim-^ioses  of  vinum  ipecacuanhfe,  every  hour 
in  severe  cases,  three  or  four  times  daily  in  those  which  are  less  urgent ; 
salicin,  in  doses  of  three  to  five  grains  three  times  a  day,  recommended 
by  Tyler  Smith ;  oxalate  of  cerium  in  the  form  of  pill,  of  which  three 
to  five  grains  may  be  given  three  times  a  day — a  remedy  strongly  advo- 
cated by  Sir  James  Simpson,  and  which  occasionally  is  of  undoubted 
service,  but  more  often  fails ;  the  compound  pyroxylic  spirit  of  the  Lon- 
don Pharmacopoeia,  in  doses  of  five  minims  every  four  hours,  with  a 
little  compound  tincture  of  cardamom — a  drug  which  is  comparatively 
little  known,  but  which  occasionally  has  a  very  marked  and  beneficial 
effect  in  checking  vomiting ;  opiates  in  various  forms — which  sometimes 
prove  useful,  more  often  not — may  be  administered  either  by  the  mouth, 
in  pills  containing  from  half  a  grain  tO  a  grain  of  opium,  or  in  small 
doses  of  the  solution  of  the  bimeconate  of  morphia  or  of  Battley's  seda- 
tive solution,  or  subcutaneously — a  mode  of  administration  which  is 
much  more  often  successful.  If  there  is  much  tenderness  about  the  epi- 
gastrium, one  or  two  leeches  may  be  advantageously  applied,  or  one- 
third  of  a  grain  of  morphia  may  be  sprinkled  on  the  surface  of  a  small 
blister,  or  cloths  saturated  in  laudanum  may  be  kept  over  the  pit  of  the 
stomach.  The  administration  per  rectum  of  twenty  grains  of  chloral, 
combined  with  the  same  amount  of  bromide  of  potassium,  in  a  small 
enema,  is  said  to  be  very  useful.  In  many  cases  I  have  found  that  the 
application  of  a  spinal  ice-bag  to  the  cervical  vertebrae,  in  the  manner 
recommended  by  Dr.  Chapman,  has  checked  the  vomiting  when  all 
drugs  have  failed.  The  ice  may  be  placed  in  one  of  Chapman's  spinal 
ice-bags,  and  applied  for  half  an  hour  or  an  hour  twice  or  three  times  a 
day.  It  invariably  produces  a  comforting  sensation  of  ^varmth,  which 
is  always  agreeable  to  the  patient.  Ice  may  be  given  to  suck  ad  libitum, 
and  is  very  useful ;  while,  if  there  be  much  exhaustion,  small  quantities 
_of  iced  champagne  may  also  be  given  from  time  to  time. 

Local  Treatment. — Inasmuch  as  the  vomiting  unquestionably  has  its 


DISEASES  OF  PREGNANCY.  201 

origin  in  the  uterus,  it  is  only  natural  that  practitioners  should  endeavor 
to  check  it  by  remedies  calculated  to  relieve  the  irritability  of  that  organ. 
Thus,  morphia  in  the  form  of  pessaries  per  vaginam,  or  belladonna  f 
applied  to  the  cervix,  has  been  recommended ;  the  former  especially  are  ! 
often  of  undoubted  service.  A  pessary  containing  one-third  to  half  a  — 
grain  of  morphia  may  be  introduced  night  and  morning  without  inter- 
fering with  other  methods  of  treatment.  Dr.  Henry  Bennet  directs 
especial  attention  to  the  cervix,  which,  he  says,  is  almost  always  con- 
gested and  inflamed  and  covered  with  granular  erosions.  This  condition 
he  recommends  to  be  treated  by  the  application  of  nitrate  of  silver 
through  the  speculum.  Dr.  Clay  of  Manchester  corroborates  this  view, 
and  strongly  advocates,  especially  when  vomiting  continues  in  the  latter 
months,  that  one  or  two  leeches  should  be  applied  to  the  cervix.  Excep- 
tion may  fairly  be  taken  to  both  these  methods  of  treatment  as  being 
somewhat  hazardous,  unless  other  means  have  been  tried  and  failed.  I 
have  little  doubt,  however,  that  in  many  cases  a  state  of  uterine  conges- 
tion is  an  important  factor  in  keeping  up  the  unduly  irritable  condition 
of  the  uterine  fibres,  and  an  endeavor  should  always  be  made  to  lessen 
it  by  insisting  on  absolute  rest  in  the  recumbent  posture.  Of  the  import- 
ance of  this  precaution  in  obstinate  cases  there  can  be  no  question.  Dr. 
Chapman  of  Norwich  strongly  recommended  dilatation  of  the  cervix  by 
the  finger,  and  stated  that  he  found  it  very  serviceable  in  checking  nausea. 
It  is  obvious  that  this  treatment  must  be  adopted  with  great  caution,  as, 
roughly  performed,  it  might  lead  to  the  production  of  abortion.  Dr. 
Hewitt's  views  as  to  the  dependence  of  sickness  on  flexions  of  the  uterus 
have  already  been  adverted  to,  and  reasons  have  been  given  for  doubting 
the  general  correctness  of  his  theory.  It  is  quite  likely,  however,  that 
well-marked  displacements  of  the  uterus,  either  forward  or  backward, 
may  serve  to  intensify  the  irritability  of  the  organ.  Cazeaux  mentions  an 
obstinate  case  immediately  cured  by  replacing  a  retrovertecl  uterus.  A 
careful  vaginal  examination  should  therefore  be  instituted  in  all  intract- 
able cases,  and  if  distinct  displacement  be  detected  an  endeavor  should  be 
made  to  support  the  uterus  in  its  normal  axis.  If  retroverted,  a  Hodge's 
pessary  may  be  safely  employed  ;  if  anteverted,  a  small  air-ball  pessary, 
as  recommended  by  Hewitt,  should  be  inserted.  I  believe,  however, 
that  such  displacements  are  the  exception,  rather  than  the  rule,  in  cases 
of  severe  sickness. 

Importance  of  Promoting  the  Nutrition  of  the  Patient. — The  im]3ort- 
ance  of  promoting  nutrition  by  every  means  in  our  power  should  always/ 
be  borne  in  mind.  The  effervescing  koumiss,  which  can  now  be  readily  j 
obtained,  I  have  found  of  great  value,  as  it  can  often  be  retained  when 
all  other  aliment  is  rejected.  The  exhaustion  produced  by  want  of  food 
soon  increases  the  irritable  state  of  the  nervous  system,  and  if  the  stom- 
ach will  not  retain  anything,  we  can  only  combat  it  by  occasional  nutri- 
ent enemata  of  strong  beef-tea,  yelk  of  egg,  and  the  like. 

The  Production^  of  Artificial  Abortion. — Finally,  in  the  worst  class 
of  cases,  when  all  treatment  has  failed  and  when  the  patient  has  fallen 
into  the  condition  of  extreme  prostration  already  described,  we  may  be 
driven  to  consider  the  necessity  of  producing  abortion.  Fortunately, 
cases  justifying  this  extreme  resource  afe^ofgreat  rarity,  but  nevertheless     i 


202  PREGNANCY. 

there  is  abundant  evidence  that  every  now  and  then  women  do  die  from 
uncontrollable  vomiting  whose  lives  might  have  been  saved  had  the 
pregnancy  been  brought  to  an  end.  The  value  of  artificial  abortion  has 
been  abundantly  proved.  Indeed,  it  is  remarkable  how  rapidly  the 
serious  symptoms  disappear  when  the  uterus  is  emptied  and  the  tension 
of  the  uterine  fibres  lessened.  It  has  fortunately  but  rarely  fallen  to  my 
lot  to  have  to  perform  this  operation  for  intractable  vomiting.  In  one 
such  case  the  patient  was  reduced  to  a  state  of  the  utmost  prostration, 
having  kept  hardly  any  food  on  her  stomach  for  many  weeks,  and  ^A'hen 
I  first  saw  her  she  was  lying  in  a  state  of  low  muttering  delirium. 
Within  a  few  hours  after  abortion  was  induced  all  the  threatening  symp- 
toms had  disappeared,  the  vomiting  had  entirely  ceased,  and  she  was 
next  day  able  to  retain  and  absorb  all  that  was  given  to  her.  The  value 
of  the  operation,  therefore,  I  believe  to  be  undoubted.  Where  it  has 
failed  it  seems  to  have  been  on  account  of  undue  delay.  Owing  to  the 
natural  repugnance  which  all  must  feel  toward  this  plan,  it  has  gener- 
ally been  postponed  until  the  patient  has  been  too  exhausted  to  rally. 
,  If,  therefore,  it  is  done  at  all,  it  should  be  before  prostration  has 
advanced  so  far  as  to  render  the  operation  useless.  In  these  cases  the 
obvious  indication  is  to  lessen  the  tension  of  the  uterus  at  once,  and 
therefore  the  membranes  should  be  punctured  by  the  uterine  sound,  so  as 
to  let  the  liquor  amnii  drain  away  ;  and  this  may  of  itself  be  sufficient 
to  accomplish  the  desired  effect.  It  is  almost  needless  to  add  that  no 
one  would  be  justified  in  resorting  to  this  expedient  without  having  his 
opinion  fortified  by  consultation  with  a  fellow-practitioner. 

Other  Disorders  of  the  Digestive  System. — Other  disorders  of  the 
digestive  system  may  give  rise  to  considerable  discomfort,  but  not  to  the 
serious  peril  attending  obstinate  vomiting.  Amongst  them  are  a  loss  of 
appetite,  acidity  and  heartburn,  flatulent  distension,  and  sometimes  a 
capricious  appetite,  which  assumes  the  form  of  longing  for  strange  and 
even  disgusting  articles  of  diet.  Associated  with  these  conditions  there 
is  generally  derangement  of  the  whole  intestinal  tract,  indicated  by 
furred  tongue  and  sluggish  bowels,  and  they  are  best  treated  by  remedies 
calculated  to  restore  a  healthy  condition  of  the  digestive  organs,  such  as 
a  light,  easily-digested  diet,  mineral  acids,  vegetable  bitters,  occasional 
aperients,  bismuth  and  soda,  and  pepsin.  The  indications  for  treatment 
are  not  different  from  those  which  accompany  the  same  symptoms  in  the 
non-pregnant  state. 

Diarrhoea. — Diarrhoea  is  an  occasional  accompaniment  of  pregnancy, 
often  depending  on  errors  of  diet.  When  excessive  and  continuous  it 
has  a  decided  tendency  to  induce  uterine  contractions,  and  I  have 
frequently  observed  premature  labor  to  follow  a  sharp  attack  of  diar- 
rhoea. It  should,  therefore,  not  be  neglected,  and  if  at  all  excessive 
should  be  checked  by  the  usual  means,  such  as  chalk  mixture  with  aro- 
matic confection  and  small  doses  of  laudanum  or  chlorodyne.  The 
possibility  of  apparent  diarrhoea  being  associated  with  actual  constipa- 
tion, the  "fluid  matter  finding  its  way  past  the  solid  materials  blocking  up 
the  intestines,  should  be  borne  in  mind. 
I  Constipation. — Constipation  is  much  more  common,  and  is  indeed  a 
\_  very  general  accompaniment  of  pregnancy,  even  in  women  who  do  not 


DISEASES  OF  PREGNANCY.  203 

suffer  from  it  at  other  times.  It  partly  depends  on  the  mechanical  inter- 
ference of  the  gravid  uterus  with  the  proper  movements  of  the  intestines, 
and  partly  on  defective  innervation  of  the  bowels  resulting  from  the 
altered  state  of  the  blood.  The  first  indication  will  be  to  remedy  this 
defect  by  appropriate  diet,  such  as  fresh  fruits,  brown  bread,  oatmeal 
porridge,  etc.  Some  medicinal  treatment  will  also  be  necessary,  and  in 
selecting  the  drugs  to  be  used  care  should  be  taken  to  choose  such  as  are 
.mild  and  unirritating  in  their  action  and  tend  to  improve  the  tone  of  the 
muscular  coat  of  the  intestine.  A  small  quantity  of  aperient  mineral 
water  in  the  early  morning,  such  as  the  Hunyadi,  Friedrichshall,  or 
Pullna  water,  often  answers  very  well ;  or  an  occasional  dose  of  the  con- 
fection of  sulphur ;  or  a  pill  containing  three  or  four  grains  of  the 
extract  of  colocynth,  with  a  quarter  of  a  grain  of  the  extract  of  nux 
vomica  and  a  grain  of  extract  of  hyoscyamus  at  bedtime ;  or  a  teaspoon- 
ful  of  the  compound  liquorice  powder  in  milk  at  bedtime.  Constipation 
is  also  sometimes  effectually  combated  by  administering,  twice  daily,  a 
pill  containing  a  couple  of  grains  of  the  inspissated  ox-gall  with  a  quar- 
ter of  a  grain  of  extract  of  belladonna.  Enemata  of  soap  and  water 
are  often  very  useful,  and  have  the  advantage  of  not  disturbing  the 
digestion.  In  the  latter  months  of  pregnancy,  especially  in  the  few 
weeks  preceding  delivery,  the  irritation  produced  by  the  collection  of 
hardened  feces  in  the  bowel  is  a  not  infrequent  cause  of  the  annoying 
false  pains  which  then  so  commonly  trouble  the  patient.  In  order  to 
relieve  them  it  will  be  necessary  to  empty  the  bowels  thoroughly  by  -an 
aperient,  such  as  a  good  dose  of  castor  oil,  to  which  fifteen  or  twenty 
minims  of  laudanum  may  be  advantageously  added.  Should  the  rectum 
become  loaded  with  scybalous  masses,  it  may  be  necessary  to  break  clown 
and  remove  them  by  mechanical  means,  provided  we  are  unable  to  effect 
this  by  copious  enemata. 

Hemorrhoids. — The  loaded  state  of  the  rectum  so  common  in  preg- 
nancy, combined  with  the  mechanical  effect  of  the  pressure  of  the  gravid 
uterus  on  the  hemorrhoidal  veins,  often  produces  very  troublesome  symp- 
toms from  piles.  In  such  cases  a  regular  and  gentle  evacuation  of  the 
bowels  should  be  secured  daily,  so  as  to  lessen  as  much  as  possible  the 
congestion  of  the  veins.  Any  of  the  aperients  already  mentioned,  espe- 
cially the  sulphur  electuary,  may  be  used.  Dr.  Fordyce  Barker  ^  insists 
that,  contrary  to  the  usual  impression,  one  of  the  best  remedies  for  this 
purpose  is  a  pill  containing  a  grain  or  a  grain  and  a  half  of  powdered 
aloes,  with  a  quarter  of  a  grain  of  extract  of  nux  vomica,  and  that  cas- 
tor oil  is  distinctly  prejudicial  and  apt  to  increase  the  symptoms.  I 
have  certainly  found  it  answer  well  in  several  cases.  When  the  piles  are 
tender  and  swollen,  they  should  be  freely  covered  with  an  ointment  con- 
sisting of  four  grains  of  muriate  of  morphia  to  an  ounce  of  simple  oint- 
ment, or  with  the  ung.  gallffi  c.  opio  of  the  Pharmacopoeia;  and,  if  pro- 
truded, an  attempt  should  be  made  to  push  them  gently  above  the 
sphincter,  by  which  they  are  often  unduly  constricted.  Relief  may  also 
be  obtained  by  frequent  hot  fomentations,  and  sometimes,  when  the  piles 
are  much  swollen,  it  will  be  found  useful  to  puncture  them,  so  as  to 
lessen  the  congestion  before  any  attempt  at  reduction  is  made. 

*  The  Puerperal  Diseases,  p.  33. 


204  PREGNANCY. 

Ptyalism. — A  profuse  discharge  from  the  salivary  glands  is  an  occa- 
1  sional  distressing  accompaniment  of  pregnancy.  It  is  generally  confined 
to  the  early  months,  but  it  occasionally  continues  during  the  whole 
period  of  gestation,  and  resists  all  treatment,  only  ceasing  when  delivery 
is  oiver.  Under  such  circumstances  the  discharge  of  saliva  is  sometimes 
enormous,  amounting  to  several  quarts  a  day,  and  the  distress  and 
annoyance  to  the  patient  are  very  great.  In  one  case  under  my  care 
the  saliva  poured  from  the  mouth  all  day  long,  and  for  several  months 
the  patient  sat  with  a  basin  constantly  by  her  side,  incessantly  emptying 
her  mouth,  until  she  was  reduced  to  a  condition  giving  rise  to  really 
serious  anxiety.  This  profuse  salivation  is  no  doubt  a  purely  nervous 
disorder,  and  not  readily  controlled  by  remedies.  Astringent  gargles, 
containing  tannin  and  chlorate  of  potass,  frequent  sucking  of._i.ce  or  of 
tannin  lozenges,  inhalation  of  turpentine  and  creasote,  counter-irritation 
over  the  salivary  glands  by  blisters  or  iodine,  the  bromides,  opium 
internally,  small  doses  of  belladonna  or  atropine,  may  all  be  tried  in 
turn,  but  none  of  them  can  be  depended  on  with  any  degree  of  confi- 
dence. 

Toothache  and  Caries  of  the  Teeth. — Severe  dental  neuralgia  is  also  a 
frequent  accompaniment  of  pregnancy,  especially  in  the  early  months. 
When  purely  neuralgic,  quinine  in  tolerably  large  doses  is  the  best 
■  remedy  at  our  disposal ;  but  not  unfrequently  it  depends  on  actual 
caries  of  the  teeth,  and  attention  should  always  be  paid  to  the  condition 
of  the  teeth  when  facial  neuralgia  exists.  There  is  no  doubt  that  preg- 
nancy predisposes  to  caries,  and  the  observation  of  this  fact  has  given 
rise  to  the  old  proverb,  "  For  every  child  a  tooth."  Mr.  Oakley  Coles, 
in  an  interesting  paper  ^  on  the  condition  of  the  mouth  and  teeth  during 
pregnancy,  refers  the  prevalence  of  caries  to  the  coexistence  of  acid 
dyspepsia,  causing  acidity  of  the  oral  secretions.  There  is  much  unrea- 
sonable dread  amongst  practitioners  as  to  interfering  with  the  teeth 
during  pregnancy,  and  some  recommend  that  all  operations,  even  stop- 
ping, should  be  postponed  until  after  delivery.  It  seems  to  me  certain 
that  the  suffering  of  severe  toothache  is  likely  to  give  rise  to  far  more 
severe  irritation  than  the  operation  required  for  its  relief,  and  I  have 
frequently  seen  badly-decayed  teeth  extracted  during  pregnancy,  and 
with  only  a  beneficial  result, 
i         Afedions  of  the  Respiratory  Organs. — Amongst  the  derangements  of 

\^^  ||  the  respiratory  organs,  one  of  the  most  common  is  spasmodic  cough, 
<.  which  is  often  excessively  troublesome.  Like  many  other  of  the  sym- 
pathetic derangements  accompanying  gestation,  it  is  purely  nervous  in 
character,  and  is  unaccompanied  by  elevated  temperature,  quickened 
pulse,  or  any  distinct  auscultatory  phenomena.  In  character  it  is  not 
unlike  whooping  cough.  The  treatment  must  obviously  be  guided  by 
the  character  of  the  cough.  Expectorants  are  not  likely  to  be  of  ser- 
vice, while  benefit  may  be  derived  from  some  of  the  antispasmodic  class 
of  drugs,  such  as  belladonna,  hydrocyanic  acid,  opiates,  or  bromide  of 
potassium.  Such  remedies  iliay  be  tried  in  succession,  but  will  often  be 
>  ■'  -  jfound  to  be  of  little  value  in  arresting  the  cough.     Dyspnoea  may  also 

f^        'be  nervous  in  character,  and  sometimes  symptoms  not  unlike  those  of 

^  Trans,  of  the  Odontologiad  Society. 


DISEASES  OF  PREGNANCY.  205 

spasmodic  asthma  are  produced.  Like  the  other  sympathetic  disorders, 
it,  as  well  as  nervous  cough,  is  most  frequently  observed  during  the 
early  months.  There  is  another  form  of  dyspnoea,  not  uncommonly 
met  with,  which  is  the  mechanical^esult  of  the  interference  with  the 
action  of  the  diaphragm  and  lungs  by  the  pressure  of  the  enlarged 
uterus.  Hence  this  is  most  generally  troublesome  in  the  latter  months, 
and  continues  unrelieved  until  delivery  or  until  the  sinking  of  the  ute- 
rine tumor  which  immediately  precedes  it.  Beyond  taking  care  that  the 
pressure  is  not  increased  by  tight-lacing  or  injudicious  arrangement  of 
the  clothes,  there  is  little  that  can  be  done  to  relieve  this  form  of  breath- 
lessness. 

[In  some  instances  the  difficulty  of  respiration  is  particularly  distress- 
ing when  the  patient  attempts  to  lie  down  in  bed,  and  sleep  is  rendered 
broken  and  unrefreshing.  In  such  cases  two  points  are  indicated  :  we 
must  elevate  the  chest,  and  at  the  same  time  relieve  the  tension  of  the 
abdomen.  This  is  best  accomplished  by  the  use  of  an  inclined  plane,  in 
the  form  of  a  wide  board  padded  with  pillows,  resting  on  the  head  and 
middle  of  the  bed  at  its  two  ends.  The  patient  is  to  rest  her  back  upon 
this  in  a  half-reclining  position,  and  have  her  knees  elevated  with  a 
pillow  under  them,  on  Avhich  she  virtually,  as  it  were,  sits.  This  I 
have  found  to  give  great  relief,  especially  to  priraiparse,  who  are  apt  to 
suffer  from  diaphragmatic  pressure  and  abdominal  resistance.  Inunc- 
tion of  the  abdomen  will  also  be  found  of  value. — Ed.] 

Palpitation. — Palpitation,  like  dyspnoea,  may  be  due  either  to  sympa- 
thetic disturbance  or  to  mechanical  interference  with  the  proper  action 
of  the  heart.  When  occurring  in  weakly  women,  it  may  be  referred  to 
the  functional  derangements  which  accompany  the  chlorotic  condition 
of  the  blood  often  associated  with  pregnancy,  and  is  then  best  remedied 
by  a  general  tonic  regimen  and  the  administration  of  ferruginous  prep- 
arations. At  other  times  antispasmodic  remedies  may  be  indicated,  and 
it  is  seldom  sufficiently  serious  to  call  for  much  special  treatment. 

Syncope.. — Attacks  of  fainting  are  not  rare,  especially  in  delicate 
women  of  highly-developed  nervous  temperament,  and  are,  perhaps, 
most  common  at__or  about  the  period  of  quickening.  In  most  cases 
these  attacks  cannot  be  classed  as  cardiac,  but  are  more  probably  nerv- 
ous in  character,  and  they  are  rarely  associated  with  complete  abolition 
of  consciousness.  They  rather,  therefore,  resemble  the  condition  de- 
scribed by  the  older  authors  as  lypothcemia.  The  patient  lies  in  a  semi- 
unconscious  condition  with  a  feeble  pulse  and  widely-dilated  pupils,  and 
this  state  lasts  for  varying  periods,  from  a  few  minutes  to  half  an  hour 
or  more.  In  one  very  troublesome  case  under  my  care  they  often  re- 
curred as  frequently  as  three  or  four  times  a  day.  I  have  observed  that 
they  rarely  occur  when  the  more  common  sympathetic  phenomena  of  preg- 
nancy, especially  vomiting,  are  present.  Sometimes  they  terminate  with 
the  ordinary  symptoms  of  hysteria,  such  as  sobbing.  The  treatment 
sliould  consist  during  the  attack  in  the  administration  of  diffiisible 
stimulants,  such  as  ether,  sal-volatile,  and  valerian,  tlie  ])Mtient  being 
placed  in  the  recimibent  j)osition,  with  the  head  low.  If  frequently 
repeated  it  is  unadvisal)le  to  attempt  to  rally  the  patient  by  the  too  free 
administration  of  stinuilants.    In  the  intervals  a  generally  tonic  regimen 


206  PREGNANCY. 

and  the  administration  of  ferruginous  remedies  are  indicated.  If  they 
recur  with  great  frequency  the  daily  application  of  the  spinal  ice-bag 
has  proved  of  much  service. 

Extreme  Ancemia  and  Chlorosis. — In  connection  with  disorders  of  the 
circulatory  system  may  be  noticed  those  which  depend  on  the  state  of 
the  blood.  The  altered  condition  of  the  blood,  which  has  already  been 
described  as  a  physiological  accompaniment  of  pregnancy  (p.  139),  is 
sometimes  carried  to  an  extent  which  may  fairly  be  called  morbid ;  and 
either  on  account  of  the  deficiency  of  blood-corpuscles  or  from  the 
increase  in  its  watery  constituents  a  state  of  extreme  anaemia  and  chlo- 
rosis may  be  developed.  This  may  be  sometimes  carried  to  a  very 
serious  extent.  Thus,  Gusserow^  records  five  cases  in  which  nothing 
but  excessive  anaemia  could  be  detected,  all  of  which  ended  fatally. 
Generally,  when  such  symptoms  have  been  carried  to  an  extreme  ex- 
tent, the  patient  has  been  in  a  state  of  chlorosis  before  pregnancy.  The 
treatment  must,  of  course,  be  calculated  to  improve  the  general  nutri- 
tion and  enrich  the  impoverished  blood ;  a  light  and  easily-assimilated 
diet,  milk,  eggs,  beef-tea,  and  animal  food— if  it  can  be  taken — atten- 
tion to  the  proper  action  of  the  bowels,  a  due  amount  of  stimulants,  and 
abundance  of  fresh  air,  will  be  the  chief  indications  in  the  general  man- 
agement of  the  case.  Medicinally,  ferruginous  preparations  will  be 
required.  Some  practitioners  object,  apparently  without  sufficient  rea- 
son, to  the  administration  of  iron  during  pregnancy  as  liable  to  promote 
abortion.  This  unfounded  prejudice  may  probably  be  traced  to  the 
supposed  emmenagogue  properties  of  the  preparations  of  iron ;  but  if 
the  general  condition  of  the  patient  indicate  such  medication  they  may 
be  administered  without  any  fear.  Preparations  of  phosjihorus,  such  as 
the  phosphide  of  zinc,  or  free  phosphorus,  also  promise  favorably,  and 
are  worthy  of  trial. 

(Edema  associated  with  Hydrcemia. — Some  of  the  more  aggravated 
cases^re  associated  with  a  considerable  amount  of  serous  eifusion  into 
the  cellular  tissue,  generally  limited  to  the  lower  extremities,  but  occa- 
sionally extending  to  the  arms,  face,  and  neck,  and  even  producing 
ascites  and  pleuritic  effusion.  Under  the  latter  circumstances  this  com- 
plication is,  of  course,  of  great  gravity,  and  it  is  said  that  after  delivery 
the  disappearance  of  the  serous  effusion  may  be  accompanied  by  meta- 
stasis of  a  fatal  character  to  the  lungs  or  the  nervous  centres.  This  form 
of  oedema  must  be  distinguished  from  the  slight  cedematous  swelling  of 
the  feet  and  legs  so  commonly  observed  as  a  mechanical  result  of  the 
pressure  of  the  gravid  uterus,  and  also  from  those  cases  of  oedema  asso- 
ciated with  albuminuria.  The  treatment  must  be  directed  to  the  cause, 
while  the  disappearance  of  the  effusion  may  be  promoted  by  the  admin- 
istration of  diuretic  drinks,  the  occasional  use  of  saline  aperients,  and 
rest  in  the  horizontal  position. 

Albuminuria. — The  existence  of  albumen  in  the  urine  of  pregnant 
women  has  for  many  years  attracted  the  attention  of  obstetricians,  and  it 
is  now  well  known  to  be  associated,  in  ways  still  imperfectly  understood. 
Math  miiny  important  puerperal  diseases.  Its  presence  in  most  cases  of 
puerperal  eclampsia  was  long  ago  pointed  out  by  Lever  in  this  country 

^  Arch.f.  Oyn.,  ii.  2,  1871. 


DISEASES  OF  PREGNANCY.  207 

and  Rayer  in  France,  and  its  association  with  this  disease  gave  rise  to  the 
theory  of  the  dependence  of  the  convulsion  on  uraemia  which  is  generally 
still  entertained.  It  has  been  shown  of  late  years,  especially  by  Braxton 
Hicks,  that  this  association  is  by  no  means  so  universal  as  was  supposed  ; 
or,  rather,  that  in  some  cases  the  albuminuria  follows  and  does  not  pre- 
cede the  convulsions,  of  which  it  might  therefore  be  supposed  to  be  the 
consequence  rather  than  the  cause ;  so  that  further  investigations  as  to 
these  particular  points  are  still  required.  Modern  researches  have  shown 
that  there  is  an  intimate  connection  between  many  other  affections  and 
albuminuria ;  as,  for  example,  certain  forms  of  paralysis,  either  of  special 
nerves,  as  puerperal  amaurosis,  or  of  the  spinal  system ;  cephalalgia 
and  dizziness  ;  puerperal  mania ;  and  possibly  hemorrhage.  It  cannot, 
therefore,  be  doubted  that  albuminuria  in  the  pregnant  woman  is  liable, 
at  any  rate,  to  be  associated  ^vith  grave  disease,  although  the  present 
state  of  our  knowledge  does  not  enable  us  to  define  very  distinctly  its 
precise  mode  of  action. 

Causes  of  Puerperal  Albumiyinjria. — The  presence  of  albumen  in  the 
urine  of  pregnant  women  is  far  from  a  rare  phenomenon.  Blot  and 
Litzman  met  with  albuminuria  in  20  per  cent,  of  pregnant  women,  which 
is,  however,  far  above  the  estimate  of  other  authors ;  Fordyce  Barker  ^ 
thinks  it  occurs  in  about  1  out  of  25  cases,  or  4  per  cent.;  while  Hofmier^ 
found  it  in  137  out  of  5000  deliveries  in  the  Berlin  Gynsecological 
Institution,  or  2.74  per  cent.  As  in  the  large  majority  of  these  cases  it 
rapidly  disappears  after  delivery,  it  is  obvious  that  its  presence  must, 
in  a  large  portion  of  cases,  depend  on  temporary  causes,  and  has  not 
always  the  same  serious  importance  as  in  the  non-pregnant  state.  This 
is  further  proved  by  the  undoubted  fact  that  albumen,  rapidly  disap- 
pearing after  delivery,  is  often  found  in  urine  of  pregnant  women  who 
go  to  term  and  pass  through  labor  without  any  unfavorable  symptoms. 
Pressure  by  the  Gravid  Uterus. — The  obvious  facts  that  in  pregnancy 
the  vessels  supplying  the  kidneys  are  subjected  to  mechanical  pressure 
from  the  gravid  uterus,  and  that  congestion  of  the  venous  circulation 
of  those  viscera  must  necessarily  exist  to  a  greater  or  less  degree,  suggest 
that  here  we  may  find  an  explanation  of  the  frequent  occurrence  of  albu- 
minuria. This  view  is  further  strengthened  by  the  fact  that  the  albumen 
rarely  appears  until  after  the  fifth  month,  and  therefore  not  until  the 
uterus  has  attained  a  considerable  size  ;  and  also  that  it  is  comparatively 
more  frequently  met  with  in  primipara,  in  whom  the  resistance  of  the 
abdominal  parietes,  and  consequent  pressure,  must  be  greater  than  in 
women  who  have  already  borne  children.  It  is  indeed  probable  that 
pressure  and  consequent  venous  congestion  of  the  kidneys  have  an 
important  influence  in  its  production  ;  but  there  must  be,  as  a  rule,  some 
other  factors  in  operation,  since  an  equal  or  even  greater  amount  of  pres- 
sure is  often  exerted  by  ovarian  and  fibroid  tumors  witliout  any  such 
conse(|iicnces.  They  are  probably  complex.  One  important  condition 
is  doubtless  the  increased  amount  of  work  tlitf  kidneys  have  to  do  in 
exf;reting  the  waste  ])rodiK'ts  of  the;  fci'tus,  as  well  as  those  of  th(!  mother. 
The  inmase(l_jnlexiuJ._tei2''i(>"  throughout  the  body,  associated  with 
hyP.?l^I9P^}y  *^*f  the  heart,  known  to  exist  in  pregnancy,  also  operates  in 
^  American  Journal  of  Obalclricx,  July,  1878.  "^Berlin  kiln.  Woch.,  Sept.,  1878. 


208  PREGNANCY. 

the  same  direction.  Bat  in  tlie  large  majority  of  cases,  although  these 
conditions  are  present,  no  albuminuria  exists,  and  they  must  therefore 
be  looked  upon  as  predisposing  causes,  to  which  some  other  is  added 
before  the  albumen  escapes  from  the  vessels.  What  this  is,  generally 
escapes  our  observation,  but  probably  any  condition  producing  sudden 
hypereemia  of  the  kidneys  and  giving  rise  to  a  state  analogous  to  the 
first  stage  of  Bright's  disease — such,  lor  example,  as  suclden  exposiuie  to 
cold  and  impeded  cutaneous  action — may  be  sufficient  to  set  a  light  to 
the  match  already  prepared  by  the  existence  of  pregnancy.  It  has  more 
recently  been  pointed  out  that  a  transient  albuminuria,  disappearing  in 
a  few  days,  is  very  common  after  delivery,  and  probably  depends  on  a 
catarrhal  condition  of  the  urinary  tract.  Ingersten  observed  this  in  50 
out  of  153  deliveries,  and  in  15  only  had  any  albumen  existed  before 
the  confinement.^  In  addition  to  these  temporary  causes  it  must  not  be 
forgotten  that  pregnancy  may  supervene  in  a  patient  already  suflering 
from  Bright's  disease,  when,  of  course,  the  albumen  will  exist  in  the 
urine  from  the  commencement  of  gestation. 

The  Effects  of  Puerperal  Albuminuria. — The  various  diseases  associated 
with  the  presence  of  albumen  in  the  urine  will  require  separate  consider- 
ation. Some  of  these,  especially  puerj^eral  eclampsia,  are  amongst  the 
most  dangerous  complications  of  pregnancy.  Others,  such  as  paralysis, 
cephalalgia,  dizziness,  may  also  be  of  considerable  gravity.  The  precise 
mode  of  their  production,  and  whether  they  can  be  traced,  as  is  generally 
believed,  to  the  retention  of  urinary  elements  in  the  blood,  either  urea 
or  free  carbonate  of  ammonia  produced  by  its  decomposition,  or  whether 
the  two  are  only  common  results  of  some  undetermined  cause,  will  be  con- 
sidered when  we  come  to  discuss  puerperal  convulsions.  AVhatever  view 
may  ultimately  be  taken  on  these  points,  it  is  sufficiently  obvious  that 
albuminuria  in  a  pregnant  woman  must  constantly  be  a  source  of  much 
anxiety,  and  must  induce  us  to  look  forward  with  considerable  appre- 
hension to  the  termination  of,  the  case. 

Prognosis. — We  are  scarcely  in  possession  of  a  sufficiently  large 
number  of  observations  to  justify  any  very  accurate  conclusions  as  to  the 
risk  attending  albuminuria  during  pregnancy,  but  it  is  certainly  by  no 
means  slight.  Hofmier  believes  that  albuminuria  is_a  most  severe  com- 
plication both  for  woman  and  child,  even  when  uncomplicated  with 
eclampsia.  The  prognosis,  he  thinks,  depends  on  whether  it  is  acute  in 
its  onset — that  is,  coming  on  within  a  few  days  of  labor — or  is"  extended 
over  several  weeks.  The  former  is  more  likely  to  pass  entirely  away 
after  delivery,  while  in  the  latter  there  is  more  risk  of  the  morbid  stale 
of  the  kidneys  becoming  permanent  and  leading  to  the  establishment  of 
Bright's  disease  after  the  pregnancy  is  over.  Goubeyre  estimated  that 
49  per  cent,  of  primiparse  who  have  albuminuria,  and  who  escape 
eclampsia,  die  from  morbid  conditions  traceable  to  the  albuminuria. 
This  conclusion  is  probably  much  exaggerated,  but  if  it  even  approxi- 
mate to  the  truth  the  danger  must  be  very  great. 

Tendency  to  Produce  Abortion. — Besides  the  ultimate  risk  to  the 
mother,  albuminuria  strongly  predisposes  to  abortion,  no  doubt  on 
account  of  the  imperfect  nutrition  of  the  foetus  by  blood  impoverished 

^Zeitschriftf.  Oeburt,  Band  v.  Heft  2. 


DISEASES  OF  PREGNANCY.  209 

by  the  drain  of  albuminous  materials  through  the  kidneys.  This  fact 
has  been  observed  by  many  writers.  A  good  illustration  of  it  is  given 
by  Tanner/  who  states  that  four  out  of  seven  M^omen  he  attended 
suffering  from  Bright's  disease  during  pregnancy  aborted,  one  of  them 
three  times  in  succession. 

Symptoms. — The  symptoms  accompanying  albuminuria  in  pregnancy 
are  by  no  means  uniform  or  constantly  present.  That  which  most 
frequently  causes  suspicion  is  the  anasarca — not  only  the  oedematous 
swelling  of  the  lower  limbs  which  is  so  common  a  consequence  of  the 
pressure  of  the  gravid  uterus,  but  also  of  the  face  and  upper  extremities. 
Any  puffiness  or  infiltration  about  the  face,  or  any  oedema  about  the 
hands  or  arms,  should  always  give  rise  to  suspicion  and  lead  to  a  careful 
examination  of  the  urine.  Sometimes  this  is  carried  to  an  exaggerated 
degree,  so  that  there  is  anasarca  of  the  whole  body. 

Nervous  Phenomena. — Anomalous  nervous  symptoms — -such  as  head- 
ache, transient  dizziness,  dimness  of  vision,  spots  before  the  eyes,  in- 
ability to  see  objects  distinctly,  sickness  in  women  not  at  other  times 
suffering  from  nausea,  sleeplessness,  irrital^lity  of  temper — are  also 
often  met  with,  sometimes  to  a  slight  degree,  at  others  very  strongly 
developed,  and  should  always  arouse  suspicion.  Indeed,  knowing  as 
we  do  that  many  morbid  states  may  be  associated  with  albuminuria,  we 
should  make  a  point  of  carefully  examining  the  urine  of  all  patients 
in  whom  any  unusually  morbid  phenomena  show  themselves  during 
pregnancy. 

Character  of  the  Urine. — The  condition  of  the  urine  varies  con- 
siderably, but  it  is  generally  scanty  and  highly  colored,  and,  in  addition 
to  the  albumen,  especially  in  cases  in  which  the  albuminuria  has  existed 
for  some  time,  we  may  find  epithelium-cells,  tube-casts,  and  occasionally 
blood-corpuscles. 

Treatment. — The  treatment  must  be  based  on  what  has  been  said  as 
to  the  causes  of  the  albuminuria.  Of  course  it  is  out  of  our  power  to 
remove  the  pressure  of  the  gravid  uterus,  except  by  inducing  labor ; 
but  its  effects  may  at  least  be  lessened  by  remedies  tending  to  promote 
an  increased  secretion  of  urine,  and  thus  diminishing  the  congestion  of 
the  renal  vessels.  The  administration  of  saline  diuretics,  such  as  the 
acetate  of  potash  or  bitartrate  of  potash,  the  latter  being  given  in  the 
form  of  the  well-known  imperial  clrink,  will  best  answer  this  indication. 
The  action  of  the  bowels  may  be  solicited  by  purgatives  producing 
watery  motions,  such  as  occasional  doses  of  the  compound  jalap  powder. 
Dry  cupping  over  the  loins,  frequently  repeated,  has  a  beneficial  effect 
in  lessening  the  renal  hypersemia.  The  action  of  the  skin  should  also 
be  promoted  by  the  use  of  the  vapor  bath,  and  with  this  view  the 
Turkish  Ijatli  may  be  employed  with  great  benefit  and  perfect  safety. 
Jaborandi  and  pilocarpin  have  ])een  given  for  this  purpose,  but  have 
been  found  by  Fordyce  Barker"  to  ])roduce  a  dangerous  degree  of  de- 
pression. The  next  indication  is  to  improve  the  condition  of  the  blood 
t)y  appropriate  diet  and  medication.  A  very  light  and  easily-assimilated 
diet  should  be  ordered,  of  which  niilk  sliould  fi)rni  the  staple.  Tarnier^ 
has  recorded  several  cases  in  whicli  a  })urely  milk  diet  was  very  successful 

^  Sifjns  and  Diseases  of  Prer/nancy,  p.  42S.  ^  Aniial.  rle  Gynec,  Jan.,  1876. 

14 


210  PREGNANCY. 

in  removing  albuminuria.  Witli  the  milk,  which  should  be  skimmed, 
we  may  allow  white  of  egg  or  a  little  M'liitc  iish.  The  tincture  of  the 
perchloride  of  iron  is  the  best  medicine  we  can  give,  and  it  may  be 
advantageously  combined  with  small  doses  of  tincture  of  digitalis,  which 
acts  as  an  excellent  diuretic. 

Question  of  Inducing  Labor. — Finally,  in  obstinate  cases  we  shall 
have  to  consider  the  advisability  of  inducing  premature  labor.  The 
propriety  of  this  procedure  in  the  albuminuria  of  pregnancy  has  of  late 
years  been  much  discussed.  Spiegelberg'  is  ojajiosed  to  it,  while  Barker^ 
thinks  it  should  only  be  resorted  to  "  when  treatment  has  been  thoroughly 
and  perseveringly  tried  without  success  for  the  removal  of  symptoms  of 
so  grave  a  character  that  their  continuance  would  result  in  the  death  of 
the  patient."  Hofmeier,^  on  the  other  hand,  is  in  favor  of  the  operation, 
which  he  does  not  think  increases  the  risk  of  eclampsia,  and  may  avert 
it  altogether.  I  believe  that,  having  in  view  the  undoubted  risks  which 
attend  this  complication,  the  operation  is  unquestionably  indicated,  and 
is  perfectly  justifiable,  in  all  cases  attended  with  symptoms  of  serious 
gravity.  It  is  not  easy  ^o  lay  dow' n  any  definite  rules  to  guide  our 
decision;  but  I  should  not  hesitate  to  adopt  this  resource  in' all  cases 
in  which  the  quantity  of  albumen  is  considerable  and  progressively 
increasing,  and  in  which  treatment  has  failed  to  lessen  the  amount,  and, 
above  all,  in  every  case  attended  with  threatening  symptoms,  such  as 
severe  headache,  dizziness,  or  loss  of  sight.  The  risks  of  the  operation 
are  infinitesimal  compared  to  those  which  the  patient  would  run  in  the 
event  of  puerperal  convulsions  supervening  or  chronic  Bright's  disease 
becoming  established.  As  the  operation  is  seldom  likely  to  be  indicated 
until  the  child  has  reached  a  viable  age,  and  as  the  albuminuria  places 
the  child's  life  in  danger,  w^e  are  quite  justified  in  considering  the  mother's 
safety  alone  in  determining  on  its  performance. 

jyiabetes. — The  occurrence  of  pregnancy  in  a  woman  suffering  from 
diabetes  may  lead  to  serious  consequences,  and  has  recently  been  speci- 
ally investigated  by  Dr.  J.  Matthews  Duncan.*  This  must  be  carefully 
distinguished  from  the  physiological  glycosuria  commonly  present  at  the 
end  of  pregnancy  and  during  lactation.  It  is  probable  that  diabetic 
patients  are  inapt  to  conceive,  but  when  pregnancy  does  occur  under 
such  conditions  the  case  cannot  be  considered  devoid  of  anxiety.  From 
the  cases  collected  by  Dr.  Duncan  it  would  apj^ear  that  pregnancy  is 
very  liable  to  be  interrupted  in  its  course,  generally  by  the  death  of  the 
foetus,  which  has  very  often  occurred.  In  some  instances  no  bad  results 
have  been  observed,  while  in  others  the  patient  has  collapsed  after 
delivery.  Diabetic  coma  does  not  seem  to  have  been  observed.  Out 
of  twenty-two  pregnancies  in  diabetic  women,  four  ended  fatally,  so  that 
the  mortality  is  obviously  very  large.  Too  little  is  kno^Mi  on  this 
subject  to  justify  positive  rules  of  treatment ;  but  if  the  symptoms  are 
serious  and  increasing  it  w^ould  probably  be  justifiable  to  induce  labor 
prematurely,  so  as  to  lessen  the  strain  to  w^hich  the  patient's  constitution 
is  subjected. 

^  Lehrbuch  des  Geburi,  '^  Amer.  Journ.  of  Obstet.,  July,  1878. 

^  Op.  cit.  ^  Obsi.  Trans.,  vol.  xxiv. 


DISEASES  OF  PREGNANCY.  211 


CHAPTER  VIII. 

DISEASES  OF  PKEGNANCY  (CONTINUED). 

Disorders  of  the  Nervous  System. — There  are  many  disorders  of  the 
nervous  system  met  with  during  the  course  of  pregnancy.  Among  the 
most  common  are  morbid  irritability  of  temper  or  a  state  of  mental 
despondency  and  dread  of  the  results  of  the  labor,  sometimes  almost 
amounting  to  insanity  or  even  progressing  to  actual  mania.  These  are 
but  exaggerations  of  the  highly  susceptible  state  of  the  nervous  system 
generally  associated  with  gestation.  Want  of  sleep  is  not  uncommon, 
and,  if  carried  to  any  great  extent,  may  cause  serious  trouble  from  the 
irritability  and  exhaustion  it  produces.  In  such  cases  we  should  en- 
deavor to  lessen  the  excitable  state  of  the  nerves  by  insisting  on  the 
avoidance  of  late  hours,  overmuch  society,  exciting  amusements,  and  the 
like ;  while  it  may  be  essential  to  promote  sleep  by  the  administration 
of  sedatives,  none  answering  so  well  as  the  chloral  hydrate,  in  combi- 
nation with  large  doses  of  the  bromide  of  potassium  or  sodium,  which 
greatly  intensify  its  hypnotic  effects. 

Headaches_g.nd  Neuralgice. — Severe  headaches  and  various  intense 
neuralgise  are  common.  Amongst  the  latter  the  most  frequently  met 
with  are  pain  in  the  breasts,  due  to  the  intimate  sympathetic  connection 
of  the  mammae  with  the  gravid  uterus,  and  intense  intercostal  neuralgia, 
which  a  careless  observer  might  mistake  for  pleuritic  or  inflammatory 
pain.  The  thermometer,  by  showing  that  there  is  no  elevation  of  tem- 
perature, would  prevent  such  a  mistake.  JSTeuralgia  of  the  uterus  itself 
or  severe  pains  in  the  groins  or  thighs — the  latter  being  probably  the 
mechanical  results  of  dragging  on  the  attachments  of  the  abdominal 
muscles — are  also  far  from  uncommon.  In  the  treatment  of  such  neu- 
ralgic affections  attention  to  the  state  of  the  general  health,  and  large 
doses  of  quinine  and  ferruginous  preparations  whenever  there  is  much 
debility,  will  be  indicated.  Locally  sedative  applications,  such  as  bella- 
donna and  chloroform  liniments,  friction  with  aconite  liniment  when  the 
pain  is  limited  to  a  small  space,  and,  in  the  worst  cases,  the  subcutane- 
ous injection  of  morphia,  will  be  called  for.  Those  pains  which  appar- 
ently depend  on  mechanical  causes  may  often  be  best  relieved  by  lessen- 
ing the  traction  on  the  muscles  by  wearing  a  well-made  elastic  belt  to 
support  the  uterus. 

Parahjsis  dependinr/  on  Prefpmnci/. — Among  the  most  interesting  of 
the.  nervous  diseases  are  various  ])aralytic  affections.  Almost  all  varieties 
of  paralysis  have  been  observed,  su(;h  as  paraplegia,  hemiplegia  (com- 
])lete  or  incomplete),  facial  paralysis,  and  paralysis  of  the  nerves  of 
special  sense,  giving  rise  to  amaurosis,  deafness,  and  loss  of  taste. 
(Jhurchill  r<!cords  22  cases  of  paralysis  during  pregnancy,  collected  by 
him  from  various  sources.  A  large  munbcr  have  also  been  brought 
together  l)y  Imb(!rt  (xoubeyre  in  an  iuter(!sting  mein<jir  on  the  subject, 


212  PREGNANCY. 

and  others  are  recorded  by  Fordyce  Barker,  Joulin,  and  other  authors, 
so  that  there  can  be  no  doubt  of  the  fact  that  paralytic  aifections  are 
common  during  gestation.  In  a  large  proportion  of  the  cases  recorded 
the  paralyses  have  been  associated  with  albuminuria,  and  are  doubtless 
unemic  in  origin.  Thus  in  19  cases  related  by  Goubeyre  albuminuria 
was  present  in  all ;  Darcy,^  however,  found  no  albuminuria  in  5  out 
of  14  cases.  The  dependency  of  the  paralysis  on  a  transient  cause 
explains  the  fact  that  in  the  large  majority  of  these  cases  the  paralvsis 
was  not  permanent,  but  disappeared  shortly  after  labor.  In  every  case 
of  paralysis,  whatever  be  its  nature,  special  attention  should  be  directed 
to  the  state  of  the  urine,  and,  should  it  be  found  to  be  albuminous,  labor 
should  be  at  once  induced.  This  is  clearly  the  proper  course  to  pursue, 
and  we  should  certainly  not  be  justified  in  running  the  risk  that  must 
attend  the  progress  of  a  case  in  which  so  formidable  a  symptom  has 
already  developed  itself  When  the  cause  has  been  removed  the  eifect 
will  also  generally  rapidly  disappear,  and  the  prognosis  is  therefore,  on 
the  whole,  favorable.  Should  the  paralysis  continue  after  delivery,  the 
treatment  must  be  such  as  we  would  adopt  in  the  non-pregnant  state, 
and  small  doses  of  strychnia,  along  with  faradization  of  the  aifected 
limbs,  would  be  the  best  remedies  at  our  disposal. 

Paralyses  tchich  are  not  Urcemic  in  their  Origin. — There  are,  however, 
unquestionably  some  cases  of  puerperal  paralysis  which  are  not  ursemic 

I  in  their  origin  and  the  nature  of  which  is  somewhat  obscure.  Hemi- 
plegia may  doubtless  be  occasioned  by  cerebral  hemorrhage,  as  in  the 

;  non-pregnant  state.  Other  organic  causes  of  paralysis,  such  as  cerebral 
congestion  or  embolism,  may  now  and  again  be  met  with  during  preg- 
nancy, but  cases  of  this  kind  must  be  of  comparative  rarity.  Other 
cases  are  functional  in  their  origin.  Tarnier  relates  a  case  of  hemiplegia 
which  he  could  only  refer  to  extreme  anaemia.  Some,  again,  may  be 
hysterical.  Paraplegia  is  apparently  more  frequently  uncomiected  with 
albuminuria  than  the  other  forms  of  paralysis,  and  it  may  either  depend 
on  pressure  of  the  gravid  uterus  on  the  nerves  as  they  pass  through  the 
pelvis  or  on  reflex  action,  as  is  sometimes  observed  in  connection  with 
uterine  disease.  When  in  such  cases  the  absence  of  albuminuria  is 
ascertained  by  frequent  examination  of  the  urine,  there  is  obviously  not 
the  same  risk  to  the  patient  as  in  cases  depending  on  uraemia,  and  there- 
fore it  may  be  justifiable  to  allow  pregnancy  to  go  on  to  term,  trusting 
to  subsequent  general  treatment  to  remove  the  paralytic  symptoms.  As 
the  loss  of  power  here  depends  on  a  transient  cause,  a  favorable  prognosis 
is  quite  justifiable.  Partial  paralysis  of  one  lower  extremity,  generally 
the  left,  sometimes  occurs  from  pressure  of  the  foetal  occiput,  and 
may  continue  for  days  or  weeks,  with  a  gradual  improvement,  after 
parturition. 

Chorea. — Chorea  is  not  unfrequently  observed,  aud  forms  a  serious 
complication.  It  is  generally  met  with  in  young  women  of  delicate 
health  and  in  the  first  pregnancy.  In  a  large  proportion  of  the  cases 
the  patient  has  already  suffered  from  the  disease  before  marriage.  On 
the  occurrence  of  pregnancy  the  disposition  to  the  disease  again  becomes 
evoked  and  choreic  movements  are  re-established.     This  fact  may  be 


DISEASES  OF  PREGNANCY.  213 

explained  partly  by  the  susceptible  state  of  the  nervous  system,  partly 
by  the  impoverished  condition  of  the  blood. 

Prognosis. — That  chorea  is  a  dangerous  complication  of  pregnancy  is 
apparent  by  the  fact  that  out  of  56  cases  collected  by  Dr.  Barnes^  no  less 
than  17,  or  1  to  3,  proved  fatal.  Nor  is  it  danger  to  life  alone  that  is 
to  be  feared,  for  it  apj)ears  certain  that  chorea  is  more  apt  to  leave  per- 
manent mental  disturbance  when  it  occurs  during  pregnancy  than  at 
other  times.  It  has  also  an  unquestionable  tendency  to  bring  on  abor- 
tion or  premature  labor,  and  in  most  cases  the  life  of  the  child  is 
sacrificed. 

Treatment. — The  treatment  of  chorea  during  pregnancy  does  not  diifer 
from  that  of  the  disease  under  more  ordinary  circumstances,  and  our 
chief  reliance  will  be  placed  on  such  drugs  as  the  liquor  arsenicalis,  bro- 
mide of  potassium,  and  iron.  In  the  severe  form  of  the  disease  the 
incessant  movements  and  the  weariness  and  loss  of  sleep  may  very  seri- 
ously imperil  the  life  of  the  patient,  and  more  prompt  and  radical  meas- 
ures will  be  indicated.  If,  in  spite  of  our  remedies,  the  paroxysms  go  on 
increasing  in  severity  and  the  patient's  strength  appears  to  be  exhausted, 
our  only  resource  is  to  remove  the  most  evident  cause  by  inducing  labor. 
Generally,  the  symptoms  lessen  and  disappear  soon  after  this  is  done. 
There  can  be  no  question  that  the  operation  is  perfectly  justifiable,  and 
may  even  be  essential  under  such  circumstances.  It  should  be  borne  in 
mind  that  the  chorea  often  recurs  in  a  subsequent  pregnancy,  and  extra 
care  should  then  always  be  taken  to  prevent  its  development. 

Disorders  of  the  Urinary  Organs. — Disorders  of  the  urinary  organs 
are  of  frequent  occurrence.  Retention  of  urine  may  be  met  with, 
and  this  is  often  the  result  of  a  retroverted  uterus.  The  treatment, 
therefore,  must  then  be  directed  to  the  removal  of  the  cause.  This  sub- 
ject will  be  more  particularly  considered  when  we  come  to  discuss  that 
form  of  displacement  (p.  216) ;  but  we  may  here  point  out  that  retention 
of  urine,  if  long  continued,  may  not  only  lead  to  much  distress,  but  to 
actual  disease  of  the  coats  of  the  bladder.  Several  cases  have  been 
recorded  in  which  cystitis,  resulting  from  urinary  retention  in  pregnancy, 
eventually  caused  the  exfoliation  of  the  entire  mucous  membrane  of  the 
bladder,^  which  was  cast  oif,  sometimes  entire,  sometimes  in  shreds,  and 
occasionally  with  portions  of  the  muscular  coat  attached  to  it.  The 
possibility  of  this  formidable  accident  should  teach  us  to  be  careful  not 
to  allow  any  undue  retention  of  urine,  but  by  a  timely  use  of  the  cath- 
eter to  relieve  the  symptoms,  while  we  at  the  &~ame  time  endeavor  to 
remove  the  cause. 

Iiritahilifi/  of  the  Bladder. — Irritability  of  the  bladder  is  of  frequent 
occurrenfo.  Tii  the  early  months  it  seems  to  be  the  consequence  of 
sympathetic  initatioii  of  the  neck  of  the  bladder,  combined  with  pres- 
sure, while  in  tlie  later  months  it  is  probably  solely  produced  by  mechan- 
ical causes.  When  sevx're  it  leads  to  much  distress,  the  patient's  rest 
being  l)rokon  an<l  disturbed  by  incessant  calls  to  micturate,  and  tlie  suf- 
fering induced  may  produce  sei'ious  constitutional  disturbances.  I  have 
elsewhere  pointed  out'*  that  irritability  of  the  bladder  in  the  later  months 
of  j)regnancy  is  frequently  associated  with  an  abnormal  position  of  the 

'  Olmt.  TrariH.,  vol.  x.  '^  I  hid.,  vol.  xi.  '^  Ibid.,  vol.  xiii. 


214  PREGNANCY. 

foetus,  which  i>s  placed  transversely  or  obliquely.  The  result  is  either 
that  undue  pressure  is  applied  to  the  bladder  or  that  it  is  drawn  out  of 
its  proper  position.  The  abnormal  position  of  the  foetus  can  readily  be 
detected  by  palpation,  and  is  readily  altered  by  external  manipulation. 
In  some  of  the  cases  I  have  recorded  altering  the  position  of  the  foetus 
was  immediately  followed  by  relief,  the  symptoms  recurring  after  a  time 
when  the  foetus  had  again  assumed  an  oblique  position.  Should  the 
foetus  frequently  become  displaced,  an  endeavor  may  be  made  to  retain 
it  in  the  longitudinal  axis  of  the  uterus  by  a  proper  adaptation  of  band- 
ages or  pads.  In  cases  not  referable  to  this  cause  we  should  attempt  to 
relieve  the  bladder  symptoms  by  appropriate  medication,  such  as  small 
doses  of  liquor  potassse  if  the  urine  be  very  acid ;  tincture  of  bella- 
donna ;  the  decoction  of  triticum  repens,  an  old  but  very  serviceable 
remedy  ;  and  vaginal  sedative  pessaries  containing  morphia  or  atropine. 

[In  one  case  where  a  lady  had  borne  two  children  with  very  little 
inconvenience  I  found  great  suffering  from  the  pressure  of  the  foetus  on 
the  bladder,  commencing  as  early  as  the  fifth  month.  This  continued 
for  a  period  of  two  months,  when  she  very  fortunately  miscarried.  In 
making  a  digital  exploration  I  recognized  that  the  foetus  was  anencepha- 
lous,  and  for  this  reason  descended  too  low  in  the  pelvis. — Ed.] 

Incontinence  of  Urine. — Women  who  have  borne  many  children  are 
often  troubled  with  incontinence  of  urine  during  pregnancy,  the  water 
dribbling  away  on  the  slightest  movement.  Through  this  much  irrita- 
tion of  the  skin  surrounding  the  genitals  is  produced,  attended  with 
troublesome  excoriations  and  eruptions.  Relief  may  be  partially 
obtained  by  lessening  the  pressure  on  the  bladder  by  an  abdominal 
belt,  while  the  skin  is  protected  by  applications  of  simple  ointment  or 
glycerin. 

Phosphatic  Deposit. — Dr.  Tyler  Smith  has  directed  attention  to  a 
phosphatic  condition  of  the  urine  occurring  in  delicate  women,  whose 
constitutions  are  severely  tried  by  gestation.  This  condition  can  easily 
be  altered  by  rest,  nutritious  diet,  and  a  course  of  restorative  medicines, 
such  as  steel,  mineral  acids,  and  the  like. 

Leucorrhcea. — A  profuse  whitish  leucorrhoeal  discharge  is  very  com- 
mon during  pregnancy,  especially  in  its  latter  half  The  discharge  fre- 
quently alarms  the  patient,  but,  unless  it  is  attended  with  disagreeable 
symptoms,  it  does  not  call  for  sjaecial  treatment.  When  at  all  excessive 
it  may  lead  to  much  irritation  of  the  vagina  and  external  generative 
organs.  The  labia  may  become  excoriated  and  covered  with  small 
aphthous  patches,  and  the  whole  vulva  may  be  hot,  swollen,  and  tender. 
Warty  groyths,  similar  in  appearance  to  syphilitic  condylomata,  are 
occasionally  developed  in  pregnant  women,  unconnected  with  any  specific 
taint  and  associated  with  the  presence  of  an  irritating  leucorrhoeal  dis- 
charge. According  to  Thibiferge,^  these  resist  local  applications,  such  as 
sulphate  of  copper  or  nitrate  of  silver,  but  spontaneously  disappear  after 
delivery.  Inasmuch  as  the  leucorrhoeal  discharge  is  dependent  on  the 
congested  condition  of  the  generati^'e  organs  accompanying  pregnancy, 
we  can  hope  to  do  little  more  than  alleviate  it.  In  the  severer  forms,  as 
has  been  pointed  out  by  Henry  Bennet,  the  cervix  will  be  found  to  be 

^  Arch.  gen.  de  Med.,  1856. 


DISEASES  OF  PREGNANCY.  215 

abraded  or  covered  with  granular  erosion,  and  it  may  be  from  time  to 
time  cautiously  touched  with  the  nitrate  of  silver  or  a  solution  of  car- 
bolic acid.  Generally  speaking,  we  must  content  ourselves  with  recom- 
mending the  patient  to  wash  the  vagina  out  gently  with  diluted  Condy's 
fluid,  or  with  a  solution  of  the  sulpho-carbolate  of  zinc  of  the  strength 
of  four  grains  to  the  ounce  of  water,  or  with  plain  tepid  water.  For 
obvious  reasons,  frequent  and  strong  vaginal  douches  are  to  be 
avoided,  but  a  daily  gentle  injection,  for  the  purpose  of  ablution,  can 
do  no  harm. 

Prwritus. — A  very  distressing  pruritus  of  the  vulva  is  frequently  met  I 
with  along  with  leucorrhoea,  especially  when  the  discharge  is  of  an  acrid 
character,  which  in  some  cases  leads  to  intense  and  protracted  suffering,  ( 
forcing  the  patient  to  resort  to  incessant  friction  of  the  parts.     Pruritus,  ^ 
however,  may  exist  without  leucorrhoea,  being  apparently  sometimes  of 
a  neuralgic  character,  at  others  associated  with  aphthous  patches  on  the 
mucous  membrane,  ascarides  in  the  rectum,  or  pediculi  in  the  hairs  of 
the  mons  veneris  and  labia.     Cases  are  even  recorded  in  which  the  pru- 
ritic irritation  extended  over  the  whole  body.    The  treatment  is  difficult 
and  unsatisfactory.    Various  sedative  applications  may  be  tried,  such  as 
weak  solutions  of  Goulard's  lotion,  or  a  lotion  composed  of  an  ounce  of 
the  solution  of  the  muriate  of  morphia,  with  a  drachm  and  a  half  of 
hydrocyanic  acid,  in  six  ounces  of  water,  or  one  formed  by  mixing  one 
part  of  chloroform  with  six  of  almond  oil.     A  very  useful  form  of  \ 
medication  consists  in  the  insertion  into  the  vagina  of  a  pledget  of  cot- 
ton wool,  soaked  in  equal  parts  of  the  glycerin  of  borax  and  sulphurous  i 
acid  ;  this  may  be  inserted  at  bedtime,  and  withdrawn  in  the  morning  ' 
by  means  of  a  string  attached  to  it.     Smearing  the  parts  with  an  oint-  i 
ment  consisting  of  boracic  acid  and  vaseline  often  answers  admirably.  j_ 
In  the  more  obstinate  cases  the  solid  nitrate  of  silver  may  be  lightly 
brushed  over  the  vulva,  or,  as  recommended  by  Tarnier,  a  solution  of 
bichloride  of  mercury,  of  about  the  strength  of  two  grains  to  the  ounce, 
may  be  applied  night  and  morning.     The  state  of  the  digestive  organs 
should  always  be  attended  to,  and  aperient  mineral  water  may  be  use- 
fully administered.     When  the  pruritus  extends  beyond  the  vulva,  or 
even  in  severe  local  cases,  large  doses  of  bromide  of  potassium  may 
perhaps  be  useful  in  lessening  the  general  hypersesthetic  state  of  the 
nerves. 

(Edema  of  the  Loiver  Limbs. — Some  of  the  disorders  of  pregnancy  are 
the  direct  results  of  thie  mechanical  pressure  of  the  gravid  uterus.  The 
most  common  of  these  are  oedema  and  a  varicose  state  of  the  veins  of  the 
lower  extremities,  or  even  of  the  vulva.  The  former  is  of  little  conse- 
quence, provided  we  have  assured  ourselves  that  it  is  really  the  result 
of  pressure,  and  not  of  albuminuria,  and  it  can  generally  be  relieved  •  ^ 
by  rest  in  the  hcjrizontal  position.  A .  varicose  state  of  the  veins  of  the  X*^''*]^ 
lower  limbs  is  very  connnon,  especially  in  muftiparre,  in  whom  it  is  apt  /^ 
to  (continue  after  delivery.  Occasionally  the  veins  of  the  vulva,  and 
even  of  the  vagina,  are  also  enlai'ged  and  varicose,  producing  consider- 
able swelling  of  the  external  genitals.  Rest  in  the  recumbent  position 
and  the  use  of  an  abdominal  l)elt,  so  as  to  take  the  pressure  off  the  veins 
as  much  as  possible,  are  all  that  can  be  done;  to  reliev^e  this  trouble- 


216  PREGNANCY. 

■some  complication.  If  the  veins  of  the  legs  are  much  swollen,  some 
benefit  may  be  derived  from  an  elastic  stocking  or  a  carefully  applied 
bandage. 

Occasional  Serious  Results  from  Laceration  of  the  Veins. — Serious  and 
even  fatal  consequences  have  followed  the  accidental  laceration  of  the 
swollen  veins.  When  laceration  occurs  during  or  immediately  after 
delivery — a  not  uncommon  result  of  the  pressure  of  the  head — it  gives 
rise  to  the  formation  of  a  vaginal  thrombus.  It  has  occasionally  hap- 
pened from  an  accidental  injury  during  pregnancy,  as  in  the  cases 
recorded  by  Simpson,  in  which  death  followed  a  kick  on  the  pudenda, 
producing  laceration  of  a  varicose  vein,  or  in  one  mentioned  by  Tarnier, 
where  the  patient  fell  on  the  edge  of  a  chair.  Severe  hemorrhage  has 
followed  the  accidental  rupture  of  a  vein  in  the  leg.  The  only  satisfac- 
tory treatment  is  pressure,  applied  directly  to  the  bleeding  parts  by 
means  of  the  finger  or  by  compresses  saturated  in  a  solution  of  the  per- 
chloride  of  iron.  The  treatment  of  vaginal  thrombus  follo^dng  labor 
must  be  considered  elsewhere.  Occasionally  the  varicose  veins  inflame, 
become  very  tender  and  painful,  and  coagula  form  in  their  canals.  In 
such  cases  absolute  rest  should  be  insisted  on,  while  sedative  lotions, 
such  as  the  chloroform  and  belladonna  liniments,  should  be  applied  to 
relieve  the  pain. 

Displacements  of  the  Gravid  Uterus. — Certain  displacements  of  the 
gravid  uterus  are  met  with  which  may  give  rise  to  symptoms  of  great 
gravity. 

^Pro^a^,  which  is  rare,  is  almost  always  the  result  of  pregnancy 
occurring  in  a  uterus  which  had  been  previously  more  or  less  proeident. 
Under  such  circumstances  the  increasing  weight  of  the  uterus  will  at 
first  necessarily  augment  the  previously  existing  tendency  to  prolapse  of 
the  womb,  which  may  come  to  protrude  partially  or  entirely  beyond  the 
vulva.  In  the  great  majority  of  cases,  as  pregnancy  advances,  the  pro- 
lapse cures  itself,  for  at  about  the  fourth  or  fifth  month  the  uterus  will 
rise  above  the  pelvic  brim.  It  has  been  said  that  in  some  cases  of  com- 
plete procidentia  pregnancy  has  gone  even  to  term  with  the  uterus  lying 
entirely  outside  the  vulva.  Most  probably  these  cases  were  imjDerfectly 
observed,  the  greater  part  of  the  uterus  being  in  reality  above  the  pelvic 
brim,  a  portion  only  of  its  lower  segment  protruding  externally ;  or,  as 
has  sometimes  been  the  case,  the  protruding  portion  has  been  an  old- 
standing  hypertrophic  elongation  of  the  cervix,  the  internal  os  uteri  and 
fundus  being  normally  situated.  Should  a  prolapsed  uterus  not  rise 
into  the  abdominal  cavity  as  pregnancy  advances,  serious  symptoms  will 
be  apt  to  develop  themselves ;  for,  unless  the  pelvis  be  unusually  capa- 
cious, the  enlarging  uterus  will  get  jammed  within  its  bony  walls,  the 
rectum  and  urethra  will  be  pressed  upon,  defecation  and  micturition 
will  be  consequently  impeded,  and  severe  pain  and  much  irritation  will 
result.  In  all  probability  such  a  state  of  things  would  lead  to  abortion. 
The  possibility  of  these  consequences  should  therefore  teach  us  to  be 
careftil  in  the  management  of  every  case  of  prolapse,  however  slight,  in 
which  pregnancy  occurs.  Absolute  rest  in  the  horizontal  position 
should  be  insisted  on,  while  the  uterus  should  be  supported  in  the  23elvis 
by  a  full-sized  Hodge's  pessary,  which  should  be  worn  until  at  least  the 


DISEASES  OF  PREGNANCY.  217 

sixth  month,  when  the  uterus  would  be  fully  within  the  abdominal  cav- 
ity. After  delivery  prolonged  rest  should  be  recommended,  in  the  hope 
that  the  process  of  involution  may  be  accompanied  by  a  cure  of  the  pro- 
lapse. There  can  be  no  doubt  that  pregnancy  carried  to  term  affords  an 
opportunity  of  curing  even  old-standing  displacements  which  should  not 
be  neglected. 

Anteversion  of  the  gravid  uterus  seldom  produces  symptoms  of  conse- 
quence. In  all  probability  it  is  common  enough  when  pregnancy  occurs 
in  a  uterus  which  is  more  than  usually  anteverted  or  is  anteflexed. 
Under  such  circumstances  there  is  not  the  same  risk  of  incarceration  in 
the  pelvic  cavity  as  in  cases  in  which  pregnancy  exists  in  a  retroflexed 
uterus,  for  as  the  uterus  increases  in  size  it  rises  without  difficulty  into 
the  abdominal  cavity.  In  the  early  months  the  pressure  of  the  fundus 
on  the  bladder  may  account  for  the  irritability  of  that  viscus  then  so 
conunonly  observed.  It  will  be  remembered  that  Graily  Hewitt  attrib- 
utes great  importance  to  this  condition  as  explaining  the  sickness 
of  pregnancy — a  theory,  however,  which  has  not  met  with  general 
acceptation. 

Extreme  anteversion  of  the  uterus  at  an  advanced  period  of  pregnancy 
is  sometimes  observed  in  multipara  with  very  lax  abdominal  walls,  occa- 
sionally to  such  an  extent  that  the  uterus  falls  completely  forward  and 
downward,  so  that  the  fundus  is  almost  on  a  level  with  the  patient's 
knees.  This  form  of  pendulous  belly  may  be  associated  with  a  separa- 
tion of  the  recti  muscles,  between  which  the  womb  forms  a  ventral  hernia, 
covered  only  by  the  cutaneous  textures.  When  labor  comes  on,  this 
variety  of  displacement  may  give  rise  to  trouble  by  destroying  the  proper 
relation  of  the  uterine  and  pelvic  axes.  The  treatment  is  purely  mechani- 
cal, keeping  the  patient  lying  on  her  back  as  much  as  possible  and  sup- 
porting the  pendulous  abdomen  by  a  properly  adjusted  bandage.  A 
similar  forward  displacement  is  observed  in  cases  of  pelvic  deformity, 
and  in  the  worst  forms,  in  rachitic  and  dwarfed  women,  it  exists  to  a 
very  exaggerated  degree. 

Retroversion. — The  most  important  of  the  displacements,  in  conse- 
quence of  its  occasional  very  serious  results,  is  retroversion  of  the  gravid 
uterus.  It  was  formerly  generally  believed  that  this  was  most  commonly 
produced  by  some  accident,  such  as  a  fall,  which  dislocated  a  uterus  pre- 
viously in  a  normal  position.  Undue  distension  of  the  bladder  was  also 
considered  to  have  an  important  influence  in  its  production  by  pressing 
the  uterus  backward  and  downward. 

Its  Causes. — It  is  now  almost  universally  admitted  that,  although  the 
above-named  causes  may  possibly  sometimes  produce  it,  in  the  very  large 
proportion  of  cases  it  depends  on  pregnancy  having  occurred  in  a  uterus 
previously  retroverted  or  retroflexed.  The  merit  of  pointing  out  this 
fact  unquestionably  belongs  to  the  late  Dr.  Tyler  Smith,  and  further 
observations  have  fully  corroborated  the  correctness  of  his  views. 

In  the  large  majority  of  cases  in  which  pregnancy  occurs  in  a  uterus 
so  disp]a(;ed,  as  the  womb  enlarges  it  straightens  itself  and  rises  into  the 
abdominal  cavity,  without  giving  any  particular  trouble;  or,  as  not 
unfrecinently  hap|)ens,  the  abnormal  position  of  the  organ  interferes  so 
much  with  its  enlargement  as  to  produce  abortion.    Sometimes,  however, 


218  PREGNANCY. 

the  uterus  increases  without  leaving  the  pelvis  until  the  third  or  fourth 
month,  when  it  can  no  longer  be  retained  in  the  pelvic  cavity  without 
inconvenience.  It  then  presses  on  the  urethra  and  rectum,  and  eventu- 
ally becomes  completely  incarcerated  within  the  rigid  walls  of  the  bony 
pelvis,  giving  rise  to  characteristic  symptoms. 

Symptoms. — The  first  sign  which  attracts  attention  is  generally  some 
trouble  connected  with  micturition  in  consequence  of  pressure  on  the 
urethra.  On  examination  the  bladder  \\'\\\  often  be  found  to  be  enor- 
mously distended,  forming  a  large,  fluctuating  abdominal  tumor,  which 
the  patient  has  lost  all  power  of  emptying.  Frequently  small  quantities 
of  urine  dribble  away,  leading  the  woman  to  believe  that  she  has  passed 
water,  and  thus  the  distension  is  often  overlooked.  Sometimes  the 
obstruction  to  the  discharge  of  urine  is  so  great  as  to  lead  to  dropsical 
effusion  into  the  cellular  tissue  of  the  arms  and  legs.  This  was  very 
well  marked  in  one  of  my  cases,  and  disappeared  rapidly  after  the  blad- 
der had  been  emptied.  Difficulty  in  defecation,  tenesmus,  obstinate  con- 
stipation, and  inability  to  empty  the  bowels  become  established  about 
the  same  time.  These  symptoms  increase,  accompanied  by  some  pelvic 
pain  and  a  sense  of  weight  and  bearing  down,  until  at  last  the  patient 
applies  for  advice  and  the  true  nature  of  the  case  is  detected.  When 
the  retroversion  occurs  suddenly,  all  these  symptoms  develop  with  great 
rapidity,  and  are  sometimes  very  serious  from  the  first. 

Progress  and  Termination. — The  further  progress  is  various.  Some- 
times, after  the  uterus  has  been  incarcerated  in  the  pelvis  for  more  or 
less  time,  it  may  spontaneously  rise  into  the  abdominal  cavity,  when  all 
threatening  symptoms  will  disappear.  So  happy  a  termination  is  quite 
exceptional,  and  if  the  practitioner  should  not  interfere  and  effect  reposi- 
tion of  the  organ,  serious  and  even  fatal  consequences  may  ensue  unless 
abortion  occurs. 

Termination  if  Reduction  is  not  Effected. — The  extreme  distension  of 
the  bladder,  ancl  the  impossibility  of  relieving  it,  may  lead  to  lacerations 
of  its  coats  and  fatal  peritonitis ;  or  the  retention  of  urine  may  produce 
cystitis,  with  exfoliation  of  the  coats  of  the  bladder ;  or,  as  more  com- 
monly happens,  retention  of  urinary  elements  may  take  place,  and  death 
occur  with  all  the  symptoms  of  ursemic  poisoning.  At  other  times  the 
impacted  uterus  becomes  congested  and  inflamed,  and  eventually  sloughs, 
its  contents,  if  the  patient  survive,  being  discharged  by  fistulous  com- 
munications into  the  rectum  and  vagina.  It  need  hardly  be  said  that 
such  terminations  are  only  possible  in  cases  which  have  been  grossly  mis- 
managed or  the  nature  of  which  has  not  been  detected  till  a  late  period. 

Diagnosis. — The  diagnosis  is  not  difficult.  On  making  a  vaginal 
examination  the  finger  impinges  on  a  smooth,  round,  elastic  swelling, 
filling  up  the  lower  part  of  the  pelvis,  stretching  and  depressing  the  pos- 
terior vaginal  wall,  which  occasionally  protrudes  beyond  the  vulv^a.  On 
passing  the  finger  forward  and  upward  we  shall  generally  be  able  to 
reach  the  cervix,  high  up  behind  the  pubes  and  pressing  on  the  urethral 
canal.  In  very  complete  retroversion  it  may  be  difficult  or  impossible 
to  reach  the  cervix  at  all.  On  abdominal  examination  the  fundus  uteri 
cannot  be  felt  above  the  pelvic  brim  :  this,  as  the  retroversion  does  not 
give  rise  to  serious  symptoms  until  between  the  third  and  fourth  months. 


DISEASES  OF  PREGNANCY.  219 

should,  under  natural  circumstances,  always  be  possible.  By  bi-manual 
examination  we  can  make  out,  with  due  care,  the  alternate  relaxation 
and  contraction  of  the  uterine  parietes  characteristic  of  the  gravid  uterus, 
and  so  differentiate  the  swelling  from  any  other  in  the  same  situation. 
The  accompanying  phenomena  of  jjregnancy  will  also  prevent  any  mis- 
take of  this  kind. 

Retroversion  going  on  to  Term. — In  some  few  cases  retroversion  has 
been  supposed  to  go  on  to  term.  Strictly  speaking,  this  is  impossible ; 
but  in  the  supposed  examples,  such  as  the  well-known  case  recorded 
by  Oldham,  part  of  a  retroflexed  uterus  remained  in  the  pelvic  cavity, 
while  the  greater  part  developed  in  the  abdominal  cavity.  The  uterus 
is  therefore  divided,  as  it  were,  into  two  portions — one,  which  is  the 
flexed  fundus,  remaining  in  the  pelvis ;  the  other,  containing  the  greater 
part  of  the  foetus,  rising  above  it.  Under  these  circumstances  a  tumor 
in  the  vagina  would  exist  in  combination,  with  an  abdominal  tumor,  and 
pregnancy  might  go  on  to  term.  Considerable  difficulty  may  even  arise 
in  labor,  but  the  malposition  generally  rectifies  itself  before  it  gives  rise 
to  any  serious  results. 

Treatment. — The  treatment  of  retroversion  of  the  gravid  uterus  should 
be  taken  in  hand  as  soon  as  possible,  for  every  day's  delay  involves  an 
increase  in  the  size  of  the  uterus,  and  therefore  greater  difficulty  in 
reposition.  Our  object  is  to  restore  the  natural  direction  of  the  uterus 
by  lifting  the  fundus  above  the  promontory  of  the  sacrum.  The  first 
thing  to  be  done  is  to  relieve  the  patient  by  emptying  the  bladder,  the 
retention  of  urine  having  probably  originally  called  attention  to  the  case. 
For  this  purpose  it  is  essential  to  use  a  long  elastic  male  catheter  of  small 
size,  as  the  urethra  is  too  elongated  and  compressed  to  admit  of  the  pas- 
sage of  the  ordinary  silver  instrument.  Even  then  it  may  be  extremely' 
difficult  to  introduce  the  catheter,  and  sometimes  it  has  been  found  to  be 
quite  impossible.  Under  such  circumstances,  provided  reposition  cannot 
be  effected  without  it,  the  bladder  may  be  punctured  an  inch  or  two 
above  the  pubes  by  means  of  the  fine  needle  of  an  aspirator,  and  the_ 
urine  drawn  off.  Dieulafoy's  work  on  aspiration  proves  conclusively 
that  this  may  be  done  without  risk,  and  the  operation  has  been  success- 
fully performed  by  Schatz  and  others.  It  very  rarely  happens,  however, 
and  in  long-neglected  cases  only,  that  the  withdrawal  of  the  urine  is 
found  to  be  impossible. 

Mode  of  Effecting  Reduction. — The  bladder  being  emptied,  and  the 
bowels  being  also  opened,  if  possible,  by  copious  enemata,  we  proceed 
to  atteiii})t  reduction.  For  this  purpose  various  procedures  are  adopted. 
If  the  case  is  not  of  very  long  standing,  I  am  inclined  to  think  that  the 
gentlest  and  safest  plan  is  the  continuous  pressure  of  a  caoutchouc  bag, 
filled  with  water,  placed  in  the  vagina.  The  good  effect  of  steady  and 
long-c(jntinued  pressure  of  this  kind  was  proved  by  Tyler  Smith,  who 
effected  in  this  way  the  reduction  of  an  inverted  uterus  of  long  standing, 
and  it  is  not  difficult  to  understand  that  it  may  succeed  when  a  more 
sudden  and  violent  effort  fails.  I  have  tried  this  plan  successfully  in 
two  cases,  a  pyriform  india-rubl)er  bag  being  inserted  into  the  vagina 
and  distended  as  far  as  the  patient  could  bear  by  means  of  a  syringe. 
The  water  nmst  be  let  out  occasionally  to  allow  the  ])aticnt  to  empty 


220  PREGNANCY. 

the  bladder,  and  the  bag  immediately  refilled.  In  both  my  cases  repo- 
sition occurred  within  twenty-four  hours.  Barnes  has  failed  with  this 
method,  but  it  succeeded  so  well  in  my  cases,  and  is  so  obviously  less 
likely  to  prove  hurtful  than  forcible  reposition  with  the  hand,  that  I 
am  inclined  to  consider  it  the  preferable  procedure,  and  one  that  should 
be  tried  first.  Failing  v/ith  the  fluid  pressure,  we  should  endeavor  to 
replace  the  uterus  in  the  following  way  :  The  patient  should  be  placed 
at  the  edge  of  the  bed,  in  the  ordinary  obstetric  position,  and  thoroughly 
anesthetized.  This  is  of  importance,  as  it  relaxes  all  the  parts  and 
admits  of  much  freer  manipulation  than  is  otherwise  possible.  One  or 
more  fingers  of  the  left  hand  are  then  inserted  into  the  rectum — if  the 
patient  be  deeply  chloroformed,  it  is  quite  possible,  with  due  care,  even 
to  pass  the  whole  hand — and  an  attempt  is  then  made  to  lift  or  push  the 
fundus  above  the  promontory  of  the  sacrum.  At  the  same  time  repo- 
sition is  aided  by  drawing  down  the  cervix  with  the  fingers  of  the  right 
hand  per  vaginam.  It  has  been  insisted  that  the  pressure  should  be 
made  in  the  direction  of  one  or  other  sacro-iliac  synchrondrosis  rather 
than  directly  upward,  so  that  the  uterus  may  not  be  jammed  against 
the  projection  of  the  promontory  of  the  sacrum.  Failing  reposition 
through  the  rectum,  an  attemj)t  may  be  made  per  vaginam,  and  for  this 
some  have  advised  the  upward  pressure  of  the  cloged  fist  passed  into  the 
canal.  Others  recommend  the  hand-and-knee  position  as  facilitating 
reposition,  but  this  prevents  the  administration  of  chloroform,  which  is 
of  more  assistance  than  any  change  of  position  can  possibly  be.  Various 
complex  instruments  have  been  invented  to  facilitate  the  operation,  but 
they  are  all  more  or  less  dangerous,  and  are  unlikely  to  succeed  when 
manual  pressure  has  failed. 

As  soon  as  the  reduction  is  accomplished,  subsequent  descent  of  the 
uterus  should  be  prevented  by  a  large-sized  Hodge's  pessary,  and  the 
patient  should  be  kept  at  rest  for  some  days,  the  state  of  the  bladder 
and  bowels  being  particularly  attended  to.  When  reposition  has  been 
fairly  effected  a  relapse  is  unlikely  to  occur. 

Treatment  lohen  Reduction  is  found  Impossible. — In  cases  in  which 
reduction  is  found  to  be  impossible  our  only  resource  is  the  artificial 
induction  of  abortion.  Under  such  circumstances  this  is  imperatively 
called  for.  It  Ts  best  effected  by  puncturing  the  membranes,  the  dis- 
charge of  the  liquor  amnii  of  itself  lessening  the  size  of  the  uterus,  and 
thus  diminishing  the  pressure  to  which  the  neighboring  parts  are  sub- 
jected. After  this  reposition  may  be  possible,  or  we  may  wait  until  the 
foetus  is  spontaneously  expelled.  It  is  not  always  easy  to  reach  the  os 
uteri,  although  we  can  generally  do  so  with  a  curved  uterine  sound.  If 
we  cannot  puncture  the  membranes,  the  liquor  amnii  may  be  drawn  off 
through  the  uterine  walls  by  means  of  the  aspirator,  inserted  through 
either  the  rectum  or  vagina.  The  injury  to  the  uterine  walls  thus 
inflicted  is  not  likely  to  be  hurtful,  and  the  risk  is  certainly  far  less 
than  leaving  the  case  alone.  Naturally,  so  extreme  a  measure  would 
not  be  adopted  until  all  the  simpler  means  indicated  have  been  tried 
and  failed. 

Diseases  Coexisting  %vith  Prec/nancy. — The  pregnant  woman  is  of 
course  liable  to  contract  the  same  diseases  as  in  the  non-pregnant  state, 


DISEASES  OF  PREGNANCY.  221 

and  pregnancy  may  occur  in  women  already  the  subject  of  some  consti- 
tutional disease.  There  is  no  doubt  yet  much  to  be  learned  as  to  the 
influence  of  coexisting  disease  on  pregnancy.  It  is  certain  that  some 
diseases  are  but  little  modified  by  pregnancy,  and  that  others  are  so  to 
a  considerable  extent,  and  that  the  influence  of  the  disease  on  the  foetus 
varies  much.  The  subject  is  too  extensive  to  be  entered  into  at  any 
length,  but  a  few  words  may  be  said  as  to  some  of  the  more  important 
affections  that  are  likely  to  be  met  with. 

Eruptive  Fevers:  Small-jjox. — The  eruptive  fevers  have  often  very 
serious  consequences,  projDortionate  to  the  intensity  of  the  attack.  Of 
these  variola  has  the  most  disastrous  results,  which  are  related  in  the 
writings  of  the  older  authors,  but  which  are,  fortunately,  rarely  seen  in 
these  days  of  vaccination.  The  severe  and  confluent  forms  of  the  dis- 
ease are  almost  certainly  fatal  to  both  the  mother  and  child.  In  the 
discrete  form  and  in  modified  small-pox  after  vaccination  the  patient 
generally  has  the  disease  favorably,  and  although  abortion  frequently 
results,  it  does  not  necessarily  do  so. 

Scarlet  Fever. — If  scarlet  fever  of  an  intense  character  attacks  a  preg- 
nant woman,  abortion  is  likely  to  occur  and  the  risks  to  the  mother  are 
very  great.  The  milder  cases  run  their  course  without  the  production 
of  any  untoward  symptoms.  Should  abortion  occur,  the  well-known 
dangerous  effect  of  this  zymotic  disease  after  delivery  will  gravely  influ- 
ence the  prognosis.  Cazeaux  was  of  opinion  that  pregnant  women  are 
not  apt  to  contract  the  disease,  while  Montgomery  thought  that  the 
poison  when  absorbed  during  pregnancy  might  remain  latent  until 
delivery,  when  its  characteristic  effects  were  produced. 

31easles. — Measles,  unless  very  severe,  often  runs  its  course  without 
seriously  affecting  the  mother  or  child.  I  have  myself  seen  several 
examples  of  this.  De  Tourcoing,  however,  states  that  out  of  15  cases 
the  mother  aborted  in  7,  these  being  all  very  severe  attacks.  Some 
cases  are  recorded  in  which  the  child  was  born  with  the  rubeolous  erup- 
tion ujDon  it. 

Continued  Fevers. — The  pregnant  woman  may  be  attacked  with  any 
of  the  continued  fevers,  and,  if  they  are  at  all  severe,  they  are  apt  to 
produce  al^ortion.  Out  of  22  cases  of  typhoid,  16  aborted,  and  the 
remaining  6,  who  had  slight  attacks,  went  on  to  term ;  out  of  63  cases 
of  relapsing  fever,  abortion  or  premature  labor  occurred  in  23.  Accord- 
ing to  Schweden,  the  main  cause  of  danger  to  the  foetus  in  continued 
fevers  is  the  hyperpyrexia,  especially  when  the  maternal  temperature 
reaches  104°  or  upward.  The  fevers  do  not  appear  to  be  aggravated  as 
regards  the  morther,  and  the  same  observation  has  been  made  by  Cazeaux 
with  regard  to  this  class  of  disease  occurring  after  delivery. 

Pneumonia. — Pneumonia  seems  to  be  specially  dangerous,  for  of  1 5 
cases  collected  by  Grisolle,^  11  died — a  mortality  immensely  greater  than 
tliat  of  th(!  disease  in  general.  The  larger  pr()]X)rtion  also  aborted,  the 
cliildren  being  generally  dead,  and  the  fatal  result  is  probably  due,  as  in 
tli(!  seven;  contimied  fevers,  to  hyperpyrexia.  The  cause  of  the  mater- 
nal mortality  does  not  seem  quite  apparent,  since  the  same  danger  does  not 
appear  to  exist  in  severe  bronchitis  or  other  inflammatory  affections. 

'  Arch,  f/eii.  <lc  l\le(l ,  vol.  xii.  p.  UOl. 


222  PREGNANCY. 

Fhthisls. — Contrary  to  the  usually-received  opinion,  it  appears  cer- 
tanTlliat  pregnancy  has  no  retarding  influence  on  coexisting  phthisis, 
nor  does  the  disease  necessarily  advance  with  greater  rapidity  after 
delivery.  Out  of  27  cases  of  phthisis  collected  by  Grisolle,^  24  showed 
the  first  symptoms  of  the  disease  after  pregnancy  had  commenced. 
Phthisical  women  are  not  apt  to  conceive — a  fact  which  may  probably 
be  explained  by  the  frequent  coexistence  in  such  cases  of  uterine  disease, 
especially  severe  leucorrhoea.  The  entire  duration  of  the  phthisis  seems 
to  be  shortened,  as  it  averaged  only  nine  and  a  half  months  in  the  27 
cases  collected — a  fact  which  proves,  at  least,  that  pregnancy  has  no 
material  influence  in  arresting  its  progress.  If  we  consider  the  tax  on 
the  vital  powers  which  pregnancy  naturally  involves,  we  must  admit 
that  this  view  is  more  physiologically  probable  than  the  one  generally 
received,  and  apparently  adopted  without  any  due  grounds. 
,  Heart  Dis^use. — The  evil  effects  of  pregnancy  and  jDarturition  on 
chronic  heart  disease  have  of  late  received  much  attention  from  Sj)iegel- 
berg,  Fritsch,  Peter,  and  other  writers.  The  subject  has  been  ably  dis- 
cussed^ in  a  series  of  elaborate  papers  by  Dr.  Angus  McDonald,  which  are 
well  worthy  of  study.  Out  of  28  cases  collected  by  him,  17,  or  60  per 
cent.,  proved  fatal.  This,  no  doubt,  is  not  altogether  a  reliable  estimate 
of  the  probable  risk  of  the  complication,  but,  at  any  rate,  it  shows  the 
serious  anxiety  which  the  occurrence  of  pregnancy  in  a  patient  suffering 
from  chronic  heart  disease  must  cause.  Dr.  McDonald  refers  the  evils 
resulting  from  pregnancy  in  connection  with  cardiac  lesions  to  two 
causes :  first,  destruction  of  that  equilibrium  of  the  circulation  which 
has  been  established  by  compensatory  arrangements ;  secondly,  the 
occurrence  of  fresh  inflammatory  lesions  upon  the  valves  of  the  heart 
already  diseased. 

The  dangerous  symptoms  do  not  usually  appear  until  after  the  first 

half  of  the  pregnancy  has  passed,  and  the  pregnancy  seldom  advances 

to  term.     The  pathological  phenomena  generally  met  with  in  fatal  cases 

are  pulmonary  congestion,  especially  of  the  bronchial  mucous  membrane, 

;  and  pulmonary  oedema,  with  occasional  pneumonia  and  pleurisy.    Mitral 

1  stenosis  seems  to  be  the  form  of  cardiac  lesion  most  likely  to  j)i'ove 

I  serious,  and  next  to  this  aortic  incompetency.     The  obvious  deduction 

from  these  facts  is,  that  heart  disease,  especially  when  associated  with 

serious  symptoms,  such  as  dyspnoea,  palpitation,  and  the  like,  should  be 

considered  a  strong  contraindication  of  marriage.     When  pregnancy  has 

actually  occurred,  all  that  can  be  done  is  to  enjoin  the  careful  regulation 

of  the  life  of  the  patient,  so  as  to  avoid  exposure  to  cold  and  all  forms 

of  severe  exertion. 

Syphilis. — The  important  influence  of  syphilis  on  the  oviun  is  fully 

considered  elsewhere.    As  regards  the  mother,  its  effects  are  not  diflerent 

ifrom  those  at  other  times.     It  need  only,  therefore,  be  said  that  M^ien- 

jcver  indications  of  syphilis  in  a  pregnant  woman  exist  the  appropriate 

i  treatment  should  be  at  once  instituted  and  carried  on  during  her  gesta- 

'tion,  not  only  with  the  view  of  checking  the  progress  of  the  disease,  but 

in  the  hope  of  preventing  or  lessening  the  risk  of  abortion  or  of  the 

birth  of  an  infected  infant.     So  far  from  pregnancy  contraindicating 

^  Arch.  yen.  de  i\I('d.,  vol.  xxii.  ^  Obst.  Joum.,  1877. 


DISEASES   OF  PREGNANCY.  223 

mercurial  treatment,  there  rather  is  a  reason  for  insisting  on  it  more 
strongly.  As  to  the  precise  medication,  it  is  advisable  to  choose  a  form 
that  can  be  exhibited  continuously  for  a  length  of  time  without  pro- 
ducing serious  constitutional  results.  Small  doses  of  the  bichloride  of 
mercury,  such  as  one-sixteenth  of  a  grain,  thrice  daily,  or  of  the  iodide 
of  mercury,  or  of  the  hydrargyrum  cum  creta,  in  combination  with 
reduced  iron,  answer  this  purpose  well ;  or  in  the  early  stages  of 
pregnancy  the  mercurial  vapor  bath  or  cutaneous  inunction  may  be 
employed. 

Dr.  Weber  of  St.  Petersburg^  has  made  some  observations  showing 
the  superiority  of  the  latter  methods,  which  he  found  did  not  interfere 
with  the  course  of  pregnancy ;  the  contrary  w^as  the  case  when  the 
mercury  was  administered  by  the  mouth,  probably,  as  he  supposes,  from 
disturbance  of  the  digestive  system.  It  must  be  borne  in  mind  that  in 
married  women  it  may  sometimes  be  expedient  to  prescribe  an  anti- 
syphilitic  course  without  their  knowledge  of  its  nature,  so  that  inunction 
is  not  always  feasible. 

Epilepsy. — The  influence  of  pregnancy  on  epilepsy  does  not  appear 
to  be  as  uniform  as  might  perhaps  be  expected.  In  some  cases  the 
number  and  intensity  of  the  fits  have  been  lessened ;  in  others  the 
disease  becomes  aggravated.  Some  cases  are  even  recorded  in  which 
epilepsy  appeared  for  the  first  time  during  gestation.  On  account 
of  the  resemblance  between  epilepsy  and  eclampsia  there  is  a  natural 
apprehension  that  a  jDi'egnant  epileptic  may  suffer  from  convulsions 
during  delivery.  Fortunately,  this  is  by  no  means  necessarily  the  case, 
and  labor  often  goes  on  satisfactorily  without  any  attack. 

Jaundice,  the  result  of  acute  yellow  atrophy  of  the  liver,  is  occa- 
sionally observed,  and  is  said  to  have  been  sometimes  epidemic.  In- 
dependently of  the  grave  risks  to  the  mother,  it  is  most  likely  to  pro- 
duce abortion  or  the  death  of  the  foetus.  According  to  Davidson,^  it 
originates  in  catarrhal  icterus,  the  excretion  of  the  bile-products  being 
impeded  in  consequence  of  pregnancy,  and  their  retention  giving  rise 
to  the  fatal  blood-poisoning  which  accompanies  the  severer  forms  of  the 
disease.  Slight  and  transient  attacks  of  jaundice  may  occur  without 
being  accompanied  by  any  bad  consequences.  Their  production  is 
probably  favored  by  the  mechanical  pressure  of  the  gravid  uterus  on 
the  intestines  and  the  bile-ducts. 

Cgreinoma. — The  occurrence  of  pregnancy  in  a  woman  suffering  from 
malignant  disease  of  the  uterus  is  by  no  means  so  rare  as  might  be  sup- 
posed, and  must  naturally  give  rise  to  much  anxiety  as  to  the  result. 
The  obstetrical  treatment  of  these  cases  will  be  discussed  elsewhere. 
Shoukl  we  be  aware  of  the  existence  of  the  disease  during  gestation,  the 
(juestion  will  arise  whetlier  we  should  not  attempt  to  lessen  the  risks  of 
(ic^livery  l)y  bringing  on  abortion  or  premature  labor.  The  question  is  one 
which  is  by  no  means  easy  to  settle.  We  have  to  deal  with  a  disease  which 
is  certain  to  prove  fatal  to  the  mother  before  long,  and  tlie  progress  of 
wliicli  is  ])ro]>ably  af!celeratcd  after  laboi*,  while  the  maiii))ulations  neces- 
sary to  induce  delivery  may  very  unfavorably  influence  the  diseased 
structures.     Again,  by  such  a  measure  we  necessarily  sacrifice  the  child, 

>  Allfjfm.  Me<l.  dnil.  Zdl..  I'V-I).,  1875.  ^  Mount.  J.  Cichwi,  1807. 


224  PREGNANCY. 

while  we  are  by  no  means  certain  that  we  materially  lessen  the  danger 
to  the  mother.  The  question  cannot  be  settled  except  on  a  consideration 
of  each  particular  case.  If  we  see  the  patient  early  in  pregnancy,  by 
inducing  abortion  we  may  save  her  the  dangers  of  labor  at  term — possi- 
bly of  the  Csesarean  section — if  the  obstruction  be  great.  Under  such 
circumstances  the  operation  would  be  justifiable.  If  the  pregnancy  has 
advanced  beyond  the  sixth  or  seventh  month,  unless  the  amount  of 
malignant  deposit  be  very  small  indeed,  it  is  probable  that  the  risks  of 
labor  Mould  be  as  great  to  the  mother  as  at  term,  and  it  would  then 
be  advisable  to  give  her  the  advantage  of  the  few  months'  delay. 

Ovarian  Tumo7\ — Cases  are  occasionally  met  with  in  which  preg- 
nancy occurs  in  women  who  are  suffering  from  ovarian  tumor,  and  their 
proper  management  has  given  rise  to  considerable  discussion.  There 
can  be  no  doubt  that  such  cases  are  attended  with  very  dangerous  and 
often  fatal  consequences,  for  the  abdomen  cannot  well  accommodate  the 
gravid  uterus  and  the  ovarian  tumor,  both  increasing  simultaneously. 
The  result  is  that  the  tumor  is  subject  to  much  contusion  and  pressure, 
which  have  sometimes  led  to  the  rupture  of  the  cyst  and  the  escajje  of 
its  contents  into  the  peritoneal  cavity  ;  at  others  to  a  low  form  of  inflam- 
mation, attended  with  much  exhaustion,  the  death  of  the  patient  super- 
vening either  before  or  shortly  after  delivery.  The  danger  during  deliv- 
ery from  the  same  cause  in  the  cases  which  go  on  to  term  is  also  very 
great.  Of  13  cases  of  delivery  by  the  natural  powers,  which  I  collected 
in  a  paper  on  "  Labor  Complicated  with  Ovarian  Tumor,"  ^  far  more 
than  one-half  proved  fatal.  [In  one  instance  in  this  city  a  lady  well 
known  to  the  editor  gave  birth  to  three  of  her  four  children  during  the 
existence  of  an  ovarian  tumor.  The  children  all  lived  to  grow  up,  and 
their  mother  died  of  her  disease  at  the  age  of  75,  after  being  repeatedly 
tapped  during  fifty  years.  The  ovarian  tumor  was  discovered  by  Dr. 
Benjamin  Rush  soon  after  her  first  child  was  born  in  1 809,  and  she  was 
first  tapped  by  Dr.  Physick  in  1811.  In  1812,  1815,  and  1818  she 
gave  birth  to  the  children  mentioned,  the  third  being  delicate,  sickly, 
and  weighing  six  pounds.  This  last  died  of  phthisis  when  45  ;  one  still 
lives.^  According  to  the  teaching  of  Mr.  Lawson  Tait,  this  may  have 
been  a  parovarian  cyst,  and  not  an  ovarian  cystoma. — Ed.]  Another 
source  of  danger  is  twisting  of  the  pedicle,  and  consequent  strangulation 
of  the  cyst,  of  which  several  instances  are  recorded.  It  is  obvious,  then, 
that  the  risks  are  so  manifold  that  in  every  case  it  is  advisable  to  con- 
sider whether  they  can  be  lessened  by  surgical  treatment. 

Methods  of  Treatment. — The  means  at  our  disposal  are  either  to  induce 
labor  prematurely,  to  treat  the  tumor  by  tapping,  or  to  perform  ovari- 
otomy. The  question  has  been  particularly  discussed  by  Spencer  Wells 
in  his  works  on  Ovariotomy.,  and  by  Barnes  in  his  Obstetric  Operations. 
The  former  holds  that  the  proper  course  to  pursue  is  to  tap  the  tumor 
when  there  is  any  chance  of  its  being  materially  lessened  in  size  by  that 
procedure,  but  that  when  it  is  multilocular  or  when  its  contents  are  solid 
ovariotomy  should  be  performed  at  as  early  a  period  of  pregnancy  as 
possible.     Barnes,  on  the  other  hand,  maintains  that  the  safer  course  is 

^  Obst.  Trans.,  vol.  ix. 

[2  Trans.  Phila.  Obsiet.  Soc,  vol.  i.,  1873,  p.  G4,  reported  by  Ed.] 


DISEASES  OF  PREGNANCY.  225 

to  imitate  the  means  by  which  nature  often  meets  this  complication,  and 
bring  on  premature  labor  without  interfering  with  the  tumor.  He  thinks 
that  ovariotomy  is  out  of  the  question,  and  that  tapping  may  be  insuf- 
ficient and  leave  enough  of  the  tumor  to  interfere  seriously  with  labor. 
So  far  as  recorded  cases  go,  they  unquestionably  seem  to  show  that  tap- 
ping is  not  more  dangerous  than  at  other  times,  and  that  ovariotomy 
may  be  practised  during  pregnancy  with  a  fair  amount  of  success.  Wells 
records  10  cases  which  were  surgically  interfered  with.  In  1  tapping 
^vas  performed,  and  in  9  ovariotomy ;  and  of  these  8  recovered,  the  preg- 
nancy going  on  to  term  in  5.  On  the  other  hand,  5  cases  were  left  alone, 
and  either  went  to  term  or  spontaneous  premature  labor  supervened  ;  and 
of  these  3  died.  The  cases  are  not  sufficiently  numerous  to  settle  the 
question,  but  they  certainly  favor  the  view  taken  by  Wells  rather  than 
that  by  Barnes.  It  is  to  be  observed  that  unless  we  give  up  all  hope 
of  saving  the  child  and  induce  abortion,  the  risk  of  induced  premature 
labor,  when  the  pregnancy  is  sufficiently  advanced  to  hope  for  a  viable 
child,  would  almost  be  as  great  as  that  of  labor  at  term ;  for  the  ques- 
tion of  interference  will  only  have  to  be  considered  with  regard  to  large 
tumors,  which  would  be  nearly  as  much  affected  by  the  pressure  of  a 
gravid  uterus  at  seven  or  eight  months  as  by  one  at  term.  Small  tumors 
generally  escape  attention,  and  are  more  apt  to  be  impacted  before  the 
presenting  part  in  delivery.  The  success  of  ovariotomy  during  preg- 
nancy has  certainly  been  great,  and  we  have  to  bear  in  mind  that  the 
woman  must  necessarily  be  subjected  to  the  risk  of  the  operation  sooner 
or  later,  so  that  we  cannot  judge  of  the  case  as  one  in  which  abortion  ter- 
minates the  risk.  Even  if  the  operation  should  put  an  end  to  the  preg- 
nancy— and  there  is  at  least  a  fair  chance  that  it  will  not  do  so — ^there  is 
no  certainty  that  that  would  increase  the  risk  of  the  operation  to  the 
mother,  while  as  regards  the  child  we  should  only  have  the  same  result 
as  if  we  intentionally  produced  abortion.  On  the  whole,  then,  it  seems 
that  the  best  chance  to  the  mother,  and  certainly  the  best  to  the  child,  is 
to  resort  to  the  apparently  heroic  practice  recommended  by  Wells.  The 
determination  must,  however,  be  to  some  extent  influenced  by  the  skill 
and  experience  of  the  operator.  If  the  medical  attendant  has  not  gained 
that  experience  which  is  so  essential  for  a  successful  ovariotomist,  the 
interests  of  the  mother  would  be  best  consulted  by  the  induction  of  abor- 
tion at  as  early  a  period  as  possible.  One  or  other  procedure  is  essential ; 
for,  in  spite  of  a  few  cases  in  which  several  successive  pregnancies  have 
occurred  in  women  who  have  had  ovarian  tumors,  the  risks  are  such  as 
not  to  justify  an  expectant  practice.  Should  rupture  of  the  cyst  occur, 
there  can  be  no  doubt  that  ovariotomy  should  at  once  be  resorted  to, 
with  the  view  of  removing  the  lacerated  cyst  and  its  extravasated 
contents. 

Fibroid  Tumors. — Pregnancy  may  occur  in  a  uterus  in  which  there 
are  one  or  more  fibroid  tumors.  If  these  are  situated  low  down  and  in 
a  position  likely  to  obstruct  the  passage  of  the  foetus,  they  may  very 
seriously  complicate  delivery.  When  they  are  situated  in  the  fundus  or 
body  of  the  uterus  they  may  give  rise  to  risk  from  licniorrhage  or  from 
inflammation  of  tlicsir  own  strnciturc.  Inasmuch  as  tluy  are  structurally 
similar  to  the  uterine  walls,  they  partake  of  the  growth  of  the  uterus 


226  PREGNANCY. 

during  pregnancy,  and  frequently  increase  remarkably  in  size.  Cazeaux 
says:  "I  have  known  them  in  several  instances  to  acquire  a  size  in  three 
or  four  months  Avhich  they  would  not  have  done  in  several  years  in  the 
non-pregnant  condition."  C^onversely,  they  share  in  the  involution  of 
the  uterus  after  delivery,  and  often  lessen  greatly  in  size,  or  even  entirely 
disappear.  Of  this  fact  I  have  elsewhere  recorded  several  curious  exam- 
ples ;  ^  and  many  other  instances  of  the  complete  disappearance  of  even 
large  tumors  have  been  described  by  authors  whose  accuracy  of  observa- 
tion cannot  be  questioned. 

Treatment. — The  treatment  will  vary  with  the  position  of  the  tumor. 
If  it  is  such  as  to  be  certain  to  obstruct  the  passage  of  the  child,  abor- 
tion should  be  induced  as  soon  as  possible.  If  the  tumor  is  w^ell  out 
of  the  way,  this  is  not  so  urgently  called  for.  The  principal  danger, 
then,  is  that  the  tumor  will  impede  the  post-partum  contraction  of  the 
uterus  and  favor  hemorrhage.  Even  if  this  should  happen,  the  flooding 
could  be  controlled  by  the  usual  means,  especially  by  the  injection  of  the 
perchloride  of  iron.  I  have  seen  several  cases  in  which  delivery  has 
taken  place  under  such  circumstances  without  any  untoward  accident. 
The  danger  from  inflammation  and  subsequent  extrusion  of  the  fibroid 
masses  would  probably  be  as  great  after  abortion  or  premature  labor  as 
after  delivery  at  term.  It  seems,  therefore,  to  be  the  proper  rule  to  inter- 
fere wdien  the  tumors  are  likely  to  impede  delivery,  and  in  other  cases 
to  allow  the,  pregnancy  to  go  on,  and  be  prepared  to  cope  with  any  com- 
plications as  they  arise.  The  risks  of  pregnancy  should  be  avoided  in 
every  case  in  which  uterine  fibroids  of  any  size  exist,  the  patients  being 
advised  to  lead  a  celibate  life. 

[Fibroid  tumors  may  so  obstruct  the  pelvis  as  to  make  delivery  per 
vias  naturales  impossible.  If  the  obstacle  cannot  be  forced  up  out  of  the 
pelvis  with  the  hand,  delivery  by  the  abdomen  \^A\\  be  required  if  the 
child  is  to  be  saved.  This  form  of  obstruction  makes  the  Csesarean 
operation  more  than  usually  hazardous,  and  likewise  its  modification  by 
Porro.  Ten  Cesarean  operations  have  been  performed  in  consequence 
of  obstruction  by  uterine  fibroids  in  the  United  States,  with  the  saving 
of  four  women  and  five  children.  Two  fatal  Porro  o^^erations  have  also 
been  performed. — Ed.] 


CHAPTER   IX. 

PATHOLOGY  OF  THE   DPXIDUA  AND   OVUM. 

Pathology  of  the  Decidua. — Comparatively  little  is,  unfortunately, 
known  of  the  pathological  changes  which  occur  in  the  mucous  mem- 
brane of  the  uterus  during  pregnancy.  It  is  probable  that  they  are  of 
much  more  consequence  than  is  generally  believed  to  be  the  case,  and  it 
is  certain  that  they  are  a  frequent  cause  of  abortion. 

^  Ohsl.  Trans.,  vols,  v.,  xiii.,  and  xix. 


PATHOLOGY  OF  THE  DEL'WUA   AND   OVUM. 


227 


Endometritis. — One  of  the  most  generally  observed  probably  depends 
on  endometritis  antecedent  to  conception.  A¥hen  the  impregnated  ovule 
reached  the  uterus  it  engrafted  itself  on  the  inflamed  mucous  membrane, 
which  was  in  an  unfit  condition  for  its  reception  and  growth.  A  not 
uncommon  result,  under  such  circumstances,  is  the  laceration  of  some  of 
the  decidual  vessels,  extravasation  of  the  blood  between  the  decidua  and 
the  uterine  walls,  and  consequent  abortion  at  an  early  stage  of  preg- 
nancy. As  this  morbid  state  of  the  uterine  mucous  membrane  is  likely 
to  continue  after  abortion  is  completed,  the  same  history  repeats  itself 
on  each  impregnation,  and  thus  we  may  have  constant  early  miscarriages 
produced.  It  does  not  necessarily  follow,  however,  that  the  pregnancy 
is  immediately  terminated  ^vhen  this  state  of  things  is  present.     Some^ 

Fig.  87. 


Hyportrophicd  Decidua  laid  open,  with  the  Ovum  attached  to  its  Fundal  Portion. 
(After  Duncan.) 

times  a  condition  of  hyj)erplasia  of  the  decidua  is  produced,  the  mem- 
brane becomes  nm(;h  thi(^kcned  and  hypertrophied  in  consequence  of 
proHferation  of  its  interstitial  connective  tissue,  and  the  decidual  cells 
are  greatly  incrcjascKl  in  size  (Fig.  87).  In  other  instancies  tlie  internal 
surfac(!  of  tlu!  dc'cidua  becomes  s(u(l<le<l  with  rough  polypoid  growths,^ 
depending  on  |)roliferati()ii  of  its  interstitial  tissue.  l)uncan  has  found 
that  the  hypertrophied  decidua  is  always  in  a  stat(!  of  fatty  degeneration, 
more  advanced  in  some  plaws  than  in  others.^     '^riie  result  of  tiiese  alter- 

'  Virchmih  Arr.hiv.fur  Frith.,  ISGl,  1st  ed.  '■'  Rcticarclidf  in.  Obi-id ri(:!<,  p.  29.'5. 


228  PREGNANCY. 

ations  is  frequently  to  produce  dwindling  or  death  of  the  ovum,  Mhicli, 
however,  retains  its  connection  with  the  decidua,  until,  after  a  lapse  of 
time,  the  decidua  is  expelled  in  the  form  of  a  thick  triangular  fleshy  sub- 
stance, with  the  atrophied  ovum  attached  to  some  part  of  its  inner  sur- 
face. In  other  cases,  in  which  the  hyperplasia  has  advanced  to  a  less 
extent,  the  nutrition  of  the  foetus  is  not  interfered  with,  and  pregnancy 
may  continue  to  term,  the  changes  in  the  decidua  being  recognizable  after 
delivery.  Other  diseases  besides  endometritis  may  give  rise  to  similar 
alterations  in  the  decidua,  one  of  these  being,  as  Virchow  maintains, 
syphilis.  The  converse  condition,  an  imperfect  development  of  the 
decidua,  especially  of  the  decidua  reflexa,  has  also  been  noted  as  a  cause 
of  abortion.  The  ovum  will  then  hang  loosely  in  the  uterine  cavity, 
W  ithout  the  support  which  the  gro\^i:h  of  the  decidua  reflexa  around  it 
ought  to  aflbrd,  and  its  premature  expulsion  readily  follows  (Fig.  88). 

Fio.  88. 


Imperfectly  developed  Decidua  Vera,  with  the  Ovum.    (After  Duncan.) 

Hydrorrhoea  Gravidarum. — The  peculiar  condition  know^n  as  hydror- 
rJicea  gravidarum  most  probably  depends  on  some  obscure  morbid  state 
of  the  uterine  mucous  membrane.  By  it  is  meant  a  discharge  of  clear 
watery  fluid  at  intervals  during  pregnancy.  It  may  happen  at  any  pe- 
riod of  gestation,  but  is  most  commonly  met  with  in  the  latter  months. 
It  may  commence  with  a  mere  dribbling,  or  there  may  be  a  sudden  and 
copious  discharge  of  fluid.  Afterward  "the  watery  fluid,  which  is  gener- 
ally of  a  pale  yellowish  color  and  transparent  like  the  liquor  amnii,  may 
continue  to  escape  at  intervals  for  many  weeks,  and  sometimes  in  very 
great  abundance,  so  as  to  saturate  the  ]>atient's  clothes.  Very  frequently 
it  is  expelled  in  gushes,  and  at  night  ^^•hen  the  patient  is  lying  quietly  in 
bed  ;  its  escape  is  then  probably  due  to  uterine  contraction. 

Many  theories  have  been  held  as  to  its  cause.  By  some  it  is  attributed 
to  the  rupture  of  a  cyst  placed  between  the  ovum  and  the  uterine  walls ; 
Baudelocque  referred  it  to  a  transudation  of  the  liquor  amnii  through 
the  membranes ;  while  Burgess  and  Dubois  believed  it  to  depend  on  a 


'  PATHOLOGY  OF  THE  DECIDUA   AND   OVUM.  229 

laceration  of  the  membranes  at  a  distance  from  the  os  uteri.  Mattei 
more  recently  has  attributed  it  to  the  existence  of  a  sac  between  the  chorion 
and  the  amnion.  It  may  be  that  in  some  instances  a  single  discharge  of 
fluid  may  come  from  one  of  the  two  last-mentioned  causes.  But  if  it 
be  continuous  or  repeated  another  source  must  be  sought  for.  Hegar^ 
maintains  that  it  is  the  result  of  abundant  secretion  from  the  glands  of 
the  mucous  membrane,  which  accumulates  between  the  decidua  and  chorion 
and  escapes  through  the  os  uteri.  If  this  occur,  the  decidua  is  probably 
in  a  hypertrophied  and  otherwise  morbid  state.  Hydrorrhoea  is  chiefly 
of  interest  from  the  error  of  diagnosis  it  is  likely  to  give  rise  to,  for  ^on 
being  summoned  to  a  case  in  which  watery  discharge  has  occurred  for 
the  first  time,  we  are  naturally  apt  to  suppose  that  the  membranes  have 
ruptured  and  that  labor  is  imminent.  Nor  is  there  any  very  certain 
means  of  deciding  if  this  be  so.  In  hydrorrhoea  we  find  that  pains  are 
absent,  the  os  uteri  unopened,  and  ballottement  may  be  made  out.  Even  j 
if  the  membranes  be  ruptured,  there  will  be  no  indication  for  interference 
unless  labor  has  actually  commenced ;  and  the  repetition  of  the  discharge 
and  the  continuance  of  the  pregnancy  will  soon  clear  up  the  diagnosis. 
Hydrorrhoea,  although  apt  to  alarm  the  patient,  need  not  give  rise  to  any 
anxiety.  The  pregnancy  generally  progresses  favorably  to  the  full  period, 
although  in  exceptional  cases  premature  labor  may  supervene.  No 
treatment  is  necessary,  nor  is  there  any  that  could  have  the  least  eifect 
in  controllina:  the  discharge. 

Pathology  of  the  Chorion. — The  only  important  disease  of  the  chorion 
witlTwhich  we  are  acquainted  is  the  well-known  condition  which  is  vari- 
ously described  as  uterine  hydatids,  cystic  disease  of  the  ovum,  hydatidi- 
form  degeneration  of  the  chorion,  or  vesicular  mole.  The  name  of  uterine  i 
hydatids  was  long  given  to  it  on  the  supposition  that  the  grape-lil*  vesi- 
cles which  characterize  the  disease  were  true  hydatids,  similar  to  those 
which  develop  in  the  liver  and  other  structures.  This  idea  has  long 
been  exploded,  and  it  is  now  known  as  a  certainty  that  the  disease  orig- ; 
inates  in  the  villi  of  the  chorion.  The  precise  mode  and  the  causes  of 
its  production  are,  however,  not  yet  satisfactorily  settled.  The  disease  is 
characterized  by  the  existence  in  the  cavity  of  the  uterus  of  a  large  num- 
ber of  translucent  vesicles  containing  a  clear  limpid  fluid,  which  has 
been  found  on  analysis  to  bear  close  resemblance  to  the  liquor  amnii. 
These  small  bladder-like  bodies,  which  vary  in  size  from  that  of  a  millet- 
seed  to  an  acorn,  are  often  described  as  resembling  a  bunch  of  grapes  or 
currants.  On  more  minute  examination  they  are  found  not  lo  be  each 
attached  to  independent  pedicles,  as  is  the  case  in  a  bunch  of  grapes,  but 
S(jme  of  them  grow  from  other  vesicles,  while  others  have  distinct  pedi- 
cles attached  to  the  chorion,  the  pedicles  themselves  sometimes  being  dis- 
tended by  fluid  (Fig.  89).  This  peculiar  arrangement  of  the  vesicles  is 
explained  by  their  mode  of  growth, 

Causeji  of  Cystic  Degeneration. — There  lias  been  considerable  discus- 
sion as  to  the  etiology  of  tliis  disease.  By  some  it  is  sn])])()sed  always 
to  follow  death  of  tli(!  fletiis,  and,  the  whole  developmental  energy  being 
exp(!nded  on  the  chorion,  vvhic^h  i'(itains  its  attachment  to  the  decidua, 
the  result  is  its  abnormal  growth  and  cystic  degeneration.     This  is  the 

^  Monnl.f.  Grhiirf,  1803. 


230 


PREGNANCY. 


Fig.  89. 


view  maintained  by  Gierse  and  Graily  Hewitt,  and  it  is  favored  by  the 
undoubted  fact  that  in  almost  all  cases  the  foetus  has  entirely  disap- 
peared, and  bv  the  occasional  occurrence  of  cases  of  twin  conceptions  in 
which  one  chorion  has  degenerated,  the  other  remaining  healthy  until 

term.  On  the  other  hand,  it  is  maintained 
that  the  starting-point  is  connected  with  the 
maternal  organism.  Virchow  thinks  it  orig- 
inates in  a  morbid  state  of  the  decidua,  while 
others  have  attributed  it  to  some  blood-dys- 
crasia  on  the  part  of  the  mother,  such  as 
syphilis.  There  are  many  reasons  for  be- 
lieving that  causes  of  this  nature  may  orig- 
inate the  affection.  Thus  it  is  often  found  to 
occur  more  than  once  in  the  same  person, 
and  alterations  of  a  similar  kind,  although 
limited  in  extent,  are  not  unfrequently  found 
in  connection  with  the  placenta  and  mem- 
branes of  living  children.  On  this  theory 
the  death  of  the  foetus  is  secondary,  the  con- 
sequence of  impaired  nutrition  from  the  mor- 
bid state  of  the  chorion.  The  probability 
is  that  both  views  may  be  right,  the  disease 
sometimes  following  the  death  of  the  embryo, 
and  at  others  being  the  result  of  obscure  ma- 
ternal causes. 

Its  Pathology. — The  degeneration  of  the 
chorion  villi  generally  commences  at  an  early 
period  of  j^regnancy,  before  the  placenta  has 
commenced  to  form.  In  that  case  the  entire  superficies  of  the  chorion 
becomes  affected.  The  disease,  however,  may  not  begin  until  after  the 
greater  part  of  the  chorion  villi  have  atrophied,  and  then  it  is  limited  to 
the  placenta.  The  epithelium  of  the  villi  appears  to  be  the  part  first 
affected,  and  the  whole  interior  of  the  diseased  villus  becomes  filled  with 
cells.  The  connective  tissue  of  the  villus  undergoes  a  remarkable  pro- 
liferation, and  collects  in  masses  at  individual  spots,  the  remainder  of 
the  villus  being  unaffected.  By  the  growth  of  these  elements  the  villus 
becbmes  distended  and  many  of  the  cells  liquefy,  the  intercellular  fluid 
thus  produced  widely  separating  the  connective  tissue,  so  as  to  form  a 
network  in  the  interior  of  the  villus,^  Thus  are  formed  the  peculiar 
grape-like  bodies  which  characterize  the  disease.  When  once  the  degen- 
eration has  commenced,  the  diseased  tissue  has  a  remarkable  poMcr  of 
increase,  so  that  it  sometimes  forms  a  mass  as  large  as  a  child's  head  and 
several  pounds  in  weight. 

The  nutrition  of  the  altered  chorion  is  maintained  by  its  connections 
with  the  decidua,  which  is  also  generally  diseased  and  hypertrophied. 
Sometimes  the  adhesion  of  the  mass  to  the  uterine  walls  is  very  firm, 
and  may  interfere  with  its  expulsion,  while  in  a  few  rare  cases  it  has 
been  found  that  the  villi  have  forced  their  way  into  the  substance  of  the 
uterus,  chiefly  through  the  uterine  sinuses,  and  thus  caused  atrophy  and 

'  Braxton  Hicks,  Guy^s  Hospital  Reports,  vol.  ii.,  3d  Series,  p.  380. 


Hydatidiform  Dt']a;eneration  of  the 
Chorion. 


PATHOLOGY  OF  THE  DECIDUA  AND   OVUM.  231 

thinning  of  its  muscular  structure.  Cases  of  this  kind  are  related  by 
Volkmann,  Waldeyer/  and  Barnes,  and  it  is  obvious  that  the  intimate 
adhesion  thus  effected  must  seriously  add  to  the  gravity  of  the  prognosis. 

Taking  this  view  of  the  etiology  of  this  disease,  it  is  obvious  that  it 
is  essentially  connected  with  pregnancy,  and  that  there  is  no  valid  ground 
for  maintaining,  as  has  sometimes  been  done,  that  it  may  occur  inde- 
pendently of  conception.  It  is  just  possible,  however,  that  true  entozoa 
may  form  in  the  substance  of  the  uterus,  which,  being  expelled  per  vagi- 
nam,  might  be  taken  for  the  results  of  cystic  disease,  and  thus  give  rise 
to  groundless  suspicions  as  to  the  patient's  chastity.  Hewitt  has  related 
one  case  in  which  true  hydatids,  originally  formed  in  the  liver,  had 
extended  to  the  peritoneum,  and  were  about  to  burst  through  the  vagina 
at  the  time  of  death.  This  occurred  in  an  unmarried  woman.  One  or 
two  other  examples  of  true  hydatids  forming  in  the  substance  of  the 
uterus  are  also  recorded.  A  very  interesting  case  is  also  related  by 
Hewitt  ^  in  which  undoubted  acephalocysts  were  expelled  from  the  uterus 
of  a  patient  who  ultimately  recovered.  A  careful  examination  of  the 
cyst  and  its  contents  woidd  show  their  true  nature,  as  the  echinococci 
heads,  with  their  characteristic  booklets,  would  be  discoverable  by  the 
microscope. 

It  is  also  possible  that  unfounded  suspicions  might  arise  from  the  fact 
of  a  j)atient  expelling  a  mass  of  hydatids  long  after  impregnation.  In 
the  case  of  a  widow  or  woman  living  apart  from  her  husband  serious 
mistakes  might  thus  be  made.  This  has  been  specially  pointed  out  by 
McClintock,^  who  says  :  "  Hydatids  may  be  retained  in  utero  for  many 
months  or  years,  or  a  portion  only  may  be  expelled,  and  the  residue  may 
throw  out  a  fresh  crop  of  vesicles,  to  be  discharged  on  a  future  occasion." 

Symptoms  and  Progress  of  the  Disease. — The  symptoms  of  cystic  dis- 
ease of  the  ovum  are  by  no  means  well  marked.  At  first  there  is  noth- 
ing to  point  to  the  existence  of  any  morbid  condition,  but  as  pregnancy 
advances  its  ordinary  course  is  inteffered  with.  There  is  more  general 
disturbance  of  the  health  than  there  ought  to  be,  and  the  reflex  irrita- 
tions, such  as  vomiting,  may  be  unusually  developed.  The  first  physical 
sign  remarked  is  rapid  increase  of  the  uterine  tumor,  Avhich  soon  does 
not  correspond  in  size  to  the  supposed  period  of  pregnancy.  Thus,  at 
the  third  month  the  uterus  may  be  found  to  reach  up  to  or  beyond  the 
umbilicus.  About  this  time  there  generally  are  more  or  less  profuse 
watery  and  sanguineous  discharges,  which  have  been  described  as  resem- 
bling currant-juice.  They  no  doubt  depend  on  the  breaking  down  and 
expulsion  of  the  cysts,  caused  by  painless  uterine  contractions.  They 
are  sometimes  excessive  in  amount,  recur  with  great  frequency,  and  often 
reduce;  the  patient  extremely.  Portions  of  cysts  may  now  generally  be 
found  mino-led  with  the  discharo;e,  and  sometimes  lari»;e  masses  of  them 
are  expelled  from  time  to  time.  Indeed,  the  discovery  of  portions  of 
cysts  is  the  only  certain  diagnostic  sign.  Vaginal  examination,  before 
the  OS  has  dilated,  will  give  no  information  except  the  absence  of  bal- 
lottement.  An  unusual  hai'dncss  or  density  of  the  uterus — described  l)y 
Leisliman,  who  attributes  much  im])ortan(!e  to  it,  as  "a  ])e('iiliar  doughy, 

'   Virfhnw'n  Archlv,  vol.  xliv.  p.  8G.  '^  Ohf^.  7)-aiis.,  vol.  xii. 

•'  McClintock's  DmaHen  of  Women,  p.  398. 


232  PREGNANCY. 

boggy  feeling  " — has  been  pointed  out  by  several  writers.  The  contour  of 
the  uterine  tumor,  moreover,  is  often  irregular.  In  addition,  we  of  course 
fail  to  discover  the  usual  auscultatory  signs  of  pregnancy.  All  this  may 
aid  in  diagnosis,  but  nothing  except  the  presence  of  cysts  in  the  watery 
bloody  discharge  will  enable  us  to  pronounce  with  certainty  as  to  the 
nature  of  the  disease. 

Treatment. — As  soon  as  the  diagnosis  is  established  the  indications  for 
treatment  are  obvious.  The  sooner  the  uterus  is  cleared  of  its  contents 
the  better.  Ergot  may  be  given  with  advantage  to  favor  uterine  con- 
traction and  the  expulsion  of  the  diseased  ovum.  Should  this  fail, 
more  especially  if  the  hemorrhage  be  great,  the  fingers  or  the  whole  hand 
must  be  introduced  into  the  uterus,  and  as  much  as  possible  of  the  mass 
removed.  As  the  os  is  likely  to  be  closed,  its  preliminary  dilatation  by 
sponge  or  laminaria  tents,  or  by  a  Barnes's  bag  if  it  be  already  opened 
to  some  extent,  will  in  most  cases  be  required.  If  chloroform  be  then 
administered,  the  remaining  steps  of  the  operation  will  be  easy.  On 
account  of  the  occasional  firm  adhesion  of  the  cystic  mass  to  the  uterus^ 
too  energetic  attempts  at  complete  separation  should  be  avoided.  Any 
severe  hemorrhage  after  the  operation  can  be  controlled  by  swabbing  out 
the  uterine  cavity  with  the  perchloride  of  iron  solution. 

Myxoma  Fibrosum. — Under  the  name  of  3Iyxoma  fibroswn  a  more 
rare  degeneration  of  the  chorion  has  been  described  by  Yirchow  and 
Hildebrandt,^  characterized  not  by  vesicular  but  by  fibroid  degeneration 
of  the  connective  tissue  of  the  chorion.  This  is,  however,  too  little 
understood  to  require  further  observation. 

Pathology  of  the  Placenta. — The  pathology  of  the  placenta  has  of  late 
years  attracted  much  attention,  and  it  has  an  important  practical  bear- 
ing, in  consequence  of  its  effect  on  the  child. 

Placentae  vary  considerably  in  shape.  They  may  be  crescentic,  or 
spread  over  a  considerable  surface,  in  consequence  of  the  chorion  villi 
entering  into  communication  with'a  larger  portion  of  the  decidua  than 
usual  [placentci  membrcmacea).  Such  forms,  however,  are  merely  of 
scientific  interest.  The  only  anomaly  of  shape  of  any  practical  import- 
ance is  the  formation  of  what  have  been  called  placentce  succenturia\ 
These  consist  of  one  or  more  separate  masses  of  placental  tissue,  pro- 
duced by  the  development  of  isolated  patches  of  chorion  villi.  Hold 
believes  that  they  always  form  exactly  at  the  junction  of  the  anterior 
and  posterior  walls  of  the  uterus,  which  in  early  pregnancy  is  a  mere 
line.  As  the  uterus  expands,  the  portions  of  placenta  on  each  side  of 
this  become  separated  from  each  other.  They  are  only  of  consequence 
from  the  possibility  of  their  remaining  unnoticed  in  the  uterus  after 
delivery  and  giving  rise  to  secondary  post-partum  hemorrhage.  The 
rare  form  of  double  placenta  with  a  single  cord,  figured  in  the  accom- 
panying woodcut  (Fig.  90),  was  probably  formed  in  this  way,  and  the 
supplementary  portion  in  such  a  case  might  readily  escape  notice. 

The  placenta  may  also  vary  in  dimensions.  Sometimes  it  is  of 
excessive  size,  generally  when  the  child  is  unusually  big,  but  not  unfre- 
quently  in  connection  with  hydramnios,  the  child  being  dead  and  shriv- 
elled.    In  other  cases  it  is  remarkably  small,  or  at  least  appears  to  be 

1  Monat.f.  Geburt,  May,  1865. 


PATHOLOGY  OF  THE  DECIDUA   AND   OVUM. 


233 


SO.  If  the  child  be  healthy,  this  is  probably  of  no  pathological  impoi^t- 
ance,  as  its  smallness  may  be  more  apparent  than  real,  depending  on  its 
vessels  not  being  distended  with  blood.  When  true^atrpphy  of  the  pla- 
centa exists,  the  vitality  of  the  foetus  may  be  seriously  interfered  with. 
This  condition  may  depend  either  on  a  diseased  state  of  the  chorion  villi 

Fig.  90. 


Double  Placenta,  with  Single  Cord. 

or  of  the  decidua  in  which  they  are  implanted.^  The  latter  is  the  more 
common  of  the  two  ;  and  it  generally  consists  in  hyperplasia  of  the  con- 
nective tissue  of  the  decidua,  which  presses  on  the  villi  and  vessels  and 
gives  rise  to  general  or  local  atrophy.  This  change  is  similar  in  its 
nature  to  that  observed  in  cirrhosis  of  the  liver  and  certain  forms  of 
Bright's  disease.  It  has  generally  been  ascribed  to  inflammatory 
changes,  and  under  the  name  of  placentitis  has  been  described  by  many 
authors,  and  has  been  considered  lo  be  a  common  disease.  To  it  are 
attril)uted  many  of  the  morbid  alterations  which  are  commonly  observed 
in  ])lacentae,  such  as  hepatizations,  circumscribed  purulent  deposits,  and 
adhesions  to  the  uterine  walls.  Many  modern  pathologists  have  doubted 
whether  these  changes  are  in  any  proper  sense  inflammatory.  Whit- 
taker  observes  on  this  point :  ''  The  disposition  to  reject  placentitis  alto- 
gether increases  in  modern  times.  Indeed,  it  is  ini])()ssible  to  conceive 
of  inflammation  on  the  modern  theory  (Cohnheim)  of  that  process,  since 
th(n-e  are  no  ca])illari(!s,  in  tlu;  maternal  portion  at  least,  througli  whose 
walls  a  'migration  '  might  ocf^ur,  and  there  are  no  nerves  to  regulate  the 
contractility  of  the  vessel  walls  in  the  entire  structure."     Robin  thus 

'  Wliilt.-iker,  Amer.  Joum.  of  Obifi.,  vol.  iii.  p.  229. 


234 


PREGNANCY. 


explains  the  various  pathological  changes  above  alluded  to  :  "  What  has 
been  taken  for  inflammation  of  the  placenta  is  nothing  else  than  a  (con- 
dition of  transformation  of  blood-clots  at  various  periods.  What  has 
been  regarded  as  pus  is  only  fibrin  in  the  course  of  disorganization,  and 
in  those  cases  where  true  pus  has  been  found  the  pus  did  not  come  from 
the  placenta,  but  from  an  inflammation  of  the  tissue  of  the  uterine  ves- 
sels and  an  accidental  disposition  in  the  tissue  of  the  placenta."  The 
extravasations  of  blood  here  alluded  to  are  of  very  common  occurrence, 
and  they  are  found  in  all  parts  of  the  organ — in  its  substance,  on  its 
decidual  surface,  or  immediately  below  the  amnion,  where  they  serve  as 
jjoints  of  origin  for  the  cysts  that  are  there  often  observed.  The  fibrin 
thus  deposited  undergoes  retrograde  metamorphosis,  as  in  other  parts  of 
the  body ;  it  becomes  decolorized,  it  undergoes  fatty  degeneration,  or  it 
becomes  changed  into  calcareous  masses  ;  and  in  this  way,  it  is  sup- 
posed, may  be  exjjlained  the  various  pathological  changes  which  are  so 
commonly  observed.  The  amount  of  retrograde  metamorphosis,  and 
the  precise  appearance  presented,  will  of  course  depend  on  the  time  that 
has  elapsed  since  the  blood-extravasations  took  place. 

Fatty  Degeneration, — Fatty   degeneration  of  the   placenta,  and  its 


'Wk 


O      OJ 


Fatty  Degeneration  of  the  Placenta. 

influence  on  the  nutrition  of  the  foetus,  have  been  specially  studied  in 
this  country  by  Barnes  and  Druitt.  Yellowish  masses  of  varying  sizes 
are  very  commonly  met  with  in  placentae,  and  these  are  found  to  consist, 
in  great  part,  of  molecular  fat,  mixed  with  a  fine  network  of  fibrous  tis- 
sue.    The  true  fatty  degeneration,  however,  specially  affects  the  chorion 


PATHOLOGY  OF  THE  DECIDUA   AND   OVUM. 


235 


villi  (Fig.   91).     On  microscopic  examination   they   are   found   to  be 
altered  and  misshaped  in  their  contour  and  to  be  loaded  with  fine  gran- 
ular  fat-globules.      Similar  changes  are  observed  in  the  cells  of  the 
decidua.     The  influence  on  the  foetus  will,  of  course,  depend  on  the 
extent  to  which  the  functions  of  the  villi  are  interfered  with.     The 
probable  cause- of  this  degeneration  is  no  doubt  some  obscure  alteration 
in  the  nutrition  of  the  tissue,  depending  on  the  state  of  the  mother's   , 
health.     Barnes  believes  that  syphilis  has  much  influence  in  its  produc- 
tion.    Druitt  has  pointed  out  that  some  amount  of  fatty  degeneration  is   1 
always  present  in  a  mature  placenta,  and  is  probably  connected  with  the  " 
physiological  separation  of  the  organ;  and  Goodell  has  more  recently 
suggested  that  an  unusual  amount  of  this  change  may  be  merely  an 
anticipation  of  the  natural  termination  of  the  life  of  the  placenta.^ 

Other  Jlorbid  States. — Other  morbid  states  of  the  placenta,  of  greater 
rarity,  are  occasionally  met  with,  as  an  oedematous  infiltration  of  its  tis- 
sue, always  occurring,  according  to  Lange,  in  cases  of  hydramnios, 
pigmentary  and  calcareous  deposits,  and  tumors  of  various  kinds  ;  but 
these  require  only  a  passing  mention. 

Pathology  of  the  Umbilical  Cord. — The  umbilical  cord  may  be  of  j'^' 
excessive  length,  varying  from  18  to  20  inches,  which  is  its  average 
measurement,  up  to  50  or  60  inches,  and  a  case  is  recorded  in  which  it 
even  reached  the  extraordinary  length  of  9  feet.  If  unusually  long,  it 
may  be  twisted  round  the  limbs  or  neck  of  the  child,  and  the  latter  posi- 
tion may,  in  exceptional  instances,  prove  injurious  during  labor. 

Some  authors  refer  cases  of  spontaneous  amputation  of  foetal  limbs  in 
utero  to  constrictions  by  the  umbilical  cord,  but  this  accident  is  more 
probably  produced  by  filamentous  adnexa 
of  the  amnion.  Kuots  in  the  cord  are  not 
uncommon,  and  they  result  from  the  foetus, 
in  its  movements,  passing  through  a  loop 
of  the  cord  (Fig.  92).  If  there  is  an  aver- 
age amount  of  Wharton's  jelly  in  the  cord, 
the  vessels  are  protected  from  pressure,  and 
no  bad  effects  follow.  Gery,  in  a  recent 
paper  on  this  subject,^  attempts  to  show 
that  such  knots  are  more  important  than 
is  generally  believed,  and  relates  two  cases 
in  which  he  believes  them  to  have  caused 
the  death  of  the  fretus. 

Extreme  torsion  of  the  cord,  an  exagge- ' 
ration  of  the  s]:)iral  twists  generally  observed, 
may  prove  injurious,  and  even  fatal,  to  the  i 
child,  by  obstructing  the  circulation  in  the 
vessels.  Spaeth  mentions  three  cases  in 
whicli  this  caused  tl)e  death  of  the  foetus, 
the  Cfjrd  being  twisted  until  it  was  rediujed 
to  the  thickii(!ss  of  a  thread. 

Anomalies  in  the  distril)iition  of  the  ves- 
sels of  the  cord  are  of  coniinon  oc(airren(^e. 


Fig.  92. 


J-Wi/V 


Knots  of  thu  Umbilical  Corel. 


'  Amrrir.fin  .faiinidl  of  Ohnli'lrir.-^,  vol.  ii.  p.  olio. 


The  coi'd  may  be  attached 

fj'  Union  iimlmdc,  Oct.,  1870. 


236  PREGNANCY. 

to  the  edge,  instead  of  to  the  centre,  of  the  placenta  (Jmttledorejplacmta), 
\  It  may  break  up  into  its  component  parts  before  reaching  the  placenta, 
the  vessels  running  through  the  membranes ;  and  if,  in  such  a  case, 
-  traction  on  the  cord  be  made,  the  separate  vessels  may  lacerate  and  the 
cord  become  detached.  There  may  be  two  veins  and  one  artery,  or  only 
one  vein  and  one  artery,  or  there  may  be  two  separate  cords  to  one  pla- 
centa. These  and  other  anomalies  that  might  be  mentioned  are  of  little 
practical  importance. 

Pathology  of  the  Ammon. — The  principal  pathological  condition  of 
the  amnion  with  which  we  are  acquainted  is  that  ^^'hicl^  is  associated 
with  excessive  secretion  of  the  liquor  amnii,  and  is  generally  known 
,  under  the  name  of  hydramnios,  which  term  KickP  limits  to  cases  in 
I  which  more  than  two  quarts  of  amniotic  fluid  exist.     Its  precise  cause 
is  still  a  matter  of  doubt.    By  some  it  is  referred  to  inflammation  of  the 
amnion   itself;    at  other  times  it  is  apparently  connected  with  some 
morbid  state  of  the  decidua,  which  may  be  found  diseased  and  hyper- 
trophied.    The  foetus  is  very  often  dead  and  shrivelled  and  the  placenta 
enlarged  and  edematous.     It  does  not  necessarily  follow,  however,  that 
hydramnios  causes  the  death  of  the  child.     Out  of  33  cases,  McClintock 
found  that  9  children  were  born  deacl,^  and  of  the  24  born  alive,  10  died 
within  a  few  hours ;  the  remainder  survived.     There  does  not  appear  to 
be  any  marked  relation  between  the  state  of  the  mother's  health  and  the 
occurrence  of  this  disease ;  and  it  is  certainly  not  necessarily  present 
when  the  mother  is  suifering  from  dropsical  efliisions  in  other  parts  of 
the  body.     The  theory  that  the  disease  is  of  purely  local  origin  is 
favored  by  the  fact  that  \\hen  hydramnios  occurs  in  twin  pregnancy  one 
ovum  only  is  generally  affected.     Its  effects,  as  regards  the  mother,  are 
chiefly  mechanical.     It  rarely  begins  to  show  itself  before  the  fifth  or 
j  sixth  month  of  pregnancy,  but  when  once  it  has  commenced  it  rapidly 
^  produces  a  feeling  of  discomfort  and  enlargement  altogether  beyond  that 
which  should  exist  at  the  period  of  pregnancy  which  has  been  reached. 
In  advanced  stages  the  distress  produced  is  often  very  great,  the  en- 
larged uterus  pressing  upon  the  diajihragm  and  producing  much  embar- 
rassment of  respiration.     Premature  expulsion  of  the  foetus  very  often 
1  supervenes.     Four  out  of  McClintock's  patients  died  after  labor,  show- 
I  ing  that  the  maternal  mortality  is  high — a  result  which  he  refers  to  the 
'  debilitated  state  of  the  Momen  who  were  the  subjects  of  the  disease. 

Its  Diagnosis. — The  diagnosis  is  not,  as  a  rule,  difficult.  It  has  to 
'  be  distinguished  from  ascitic  distension  of  the  abctomen,  from  enlarge- 
ment of  the  uterus  from  twin  pregnancy,  and  from  ovarian  tumor  or 
pregnancy  complicated  ^vith  ovarian  tumor.  The  first  will  be  recog- 
I  nized  by  the  superficial  position  of  the  fluid  ;  by  the  difficulty  of  feeling 
the  contour  of  the  uterus,  which  is  obscured  by  the  surrounding  fluid, 
and  the  results  of  percussion,  which  show  that  the  fluid  is  free  in  the 
peritoneal  cavity ;  and  by  the  coexistence  of  dropsical  effusions  in  other 
parts  of  the  body.  The  second  may  be  difficult,  and  even  impossible, 
to  diagnose  from  it :    generally,  however,  in  hydramnios  the  uterine 

^  "  On  the  Diagnosis  of  Dropsy  of  the  Amnion,"  Proceedings  of  the  Obstetrical  Society 
of  Dublin,  May  11,  1878. 
^  Diseases  of  Women,  p.  383. 


PATHOLOGY  OF  THE  DECIDUA  AND   OVUM.  237 

tumor  is  more  distinctly  tense  or  fluctuating,  the  foetal  limbs  cannot  be    ^^^^^ 
felt  on  palpation,  and  the  lower  segment  of  the  uterus,  as  felt  per  j  • 

vaginam,  is  unusually  distended,  the  presenting  part  not  being  appre-  ' 
oiable.     Ovarian  tumors  alone  or  complicating  pregnancy  may  also  be 
difficult  to  distinguish  from  dropsy  of  the  amnion.    The  general  history  | 
of  the  case,  and  the  presence  or  absence  of  signs  of  pregnancy,  may  [  Cnn^-^* 
enable  us  to  arrive  at  a  diagnosis ;  and  Kidd  points  out  that  the  posi- 
tion of  the  uterus,  whether  gravid  or  not,  is  usually  low  down  in  the  ; 
pelvis  in  ovarian  dropsy,  while  in  dropsy  of  the  amnion  it  is  drawn  high  ■ 
up  and  reached  with  difficulty  on  vaginal  examination. 

lU_Effect  on  Labor. — During  labor  an  excessive  amount  of  liquor 
amnii  is  often  a  causejrf  deficient  uterine  action  and  delay,  the  pains 
being  feeble  and  ineffective.     This,  of  course,  tells  chiefly  in  the  first 
stage,  wdiich  is  often  much  prolonged,  unless  the  membranes  are  punc-  j 
tured  early  and  the  superabundant  fluid  allowed  to  escape.  ' 

Treatment. — No  treatment  is  known  to  have  any  effect  on  the  disease. 
If  the  discomfort  and  distension  are  very  great,  it  may  be  absolutely  | 
necessary  to  puncture  the  membranes  and  allow  the  water  to  escape,  j 
This  inevitably  brings  on  labor.  If  the  pregnancy  be  not  sufficiently  ' 
advanced  to  give  hope  for  the  birth  of  a  living  child,  we  would  not  of 
course  resort  to  this  expedient  unless  the  mother's  health  was  seriously  i 
imperilled.  It  is  possible  that  in  such  cases  the  patient  might  be  j 
relieved  by  inserting  the  minute  needle  of  an  aspirator  through  the  j 
OS  and  removing  a  certain  quantity  of  the  liquor  amnii  by  aspiration,  | 
without  inducing  the  labor.  I  have  never  had  an  opportunity  of  trying  I 
this  expedient,  but  it  seems  a  possibility. 

Deficiency  of  Liquor  Amnii. — A  defective  amount  of  liquor  amnii  is  ;  K^/  ic,. 
said  to  favor  certain  malformations  by  allowing  the  uterus  to  compress 
the  fcetus  unduly.  It  certainly  occasionally  gives  rise  to  adhesion 
between  the  foetus  and  the  membranes,  and  to  the  formation  of  amni- 
otic bands  which  are  capable  of  producing  certain  foetal  deformities  (pp. 
235  and  240). 

Appearance  of  the  Liquor  Amnii. — The  liquor  amnii  itself  varies 
much  in  appearance.  It  is  sometimes  thick^  and  treacly,  instead  of 
limpid,  and  it  may  be  offensive  in  odor.  The  cause  of  these  variations 
is  not  Avell  understood. 

Pathology  of  the  Foetus. — There  is  abundant  evidence  that  the  foetus  +f 
in  utero  is  subject  to  many  diseases,  some  of  which  cause  its  death,  and 
others  leave  distinct  traces  of  their  existence,  although  not  proving  fatal. 
The  su])ject  is  of  great  importance,  and  is  well  worthy  of  study.  There 
is  still  nuich  to  be  done  in  this  direction  which  may  lead  to  important 
practical  results.  I  can,  however,  do  little  more  than  enumerate  some 
of  the  jirincipal  affections  which  have  been  observed. 

Blood  JJiseofies  transmitted  throw/It  the  Motlier :  tSmall-pox. — It  is  a 
wcll-cstabhslied  fa(;t  that  the  various  eruptive  fevers  from  whi(!h  the 
mother  may  suffer  may  be  communicated  to  the  fletus  in  utero.     When    ^•- 

the  mother  is  attacked  witli   confluent  sinall-j)ox  slie   almost  always " 

aborts,  but  not  netjessarily  so  when  it  is  discrete  or  modified.  In  such 
cases  it  has  often  happened  that  the  foetus  has  been  born  with  evident 
marks  of  small-]iox.     Cases  are  on  record  whicli  ])rove  that  the  foetus 


238  PREGNANCY. 

was  attacked  subsequently  to  the  mother.  Thus  a  mother  attacked  with 
small-pox  has  miscarried,  and  has  given  birth  to  a  living  child  showing 
no  trace  of  the  disease,  which,  however,  showed  itself  in  two  or  three 
days — proving  that  it  had  been  contracted,  and  had  run  through  its 
usual  period  of  incubation,  when  the  foetus  was  still  in  utero.  It  does 
not  follow,  however,  that  the  foetus  is  affected,  as  Serres  has  collected  22 
cases  in  which  women  suffering  from  small-pox  gave  birth  to  children 
who  had  not  contracted  the  disease.  It  has  been  supposed  that  in  such 
cases  the  child  is  protected  from  small-pox,  though  it  has  shown  no 
symptom  of  having  had  the  disease.  Tarnier,  however,  cites  two 
instances  in  which  such  children  had  small-pox  two  years  after  birth. 
Madge  and  Simpson  record  cases  in  which  vaccination  performed  on 
the  mother  during  pregnancy  protected  the  foetus,  on  whom  all  subse- 
quent attempts  at  vaccination  failed.  There  is  evidence  also  to  prove 
that  the  disease  may  be  transmitted  to  the  foetus  through  a  mother  who 
is  herself  unsusceptible  of  contagion,  the  child  having  been  covered  with 
small-pox  eruption,  the  mother  being  cjuite  free  from  it.  It  is  probable 
that  the  same  facts  which  have  been  observed  with  regard  to  small-jjox 
hold  true  with  reference  to  other  zymotic  diseases,  such  as  scarlet  fever 
and  measles,  although  there  is  not  sufficient  evidence  to  justify  a  posi- 
tive assertion  to  that  effect. 

3Ialaria  and  Lead-Poisoning. — Amongst  other  maternal  diseases, 
malaria  and  lead-poisoning  are  known  to  affect  the  foetus  in  utero.  Dr. 
Stokes  relates  cases  in  which  the  mother  suffered  from  tertian  ague,  the 
child  having  also  attacks,  as  evidenced  by  its  convulsive  movements,  appre- 
ciable by  the  mother,  which  took  place  at  the  regular  intervals,  but  at  a 
different  time  from  the  mother's  paroxysms.  In  other  cases  the  febrile 
paroxysm  comes  on  at  the  same  time  in  the  foetus  as  in  the  mother ;  and 
the  fact  has  been  verified  by  the  observation  that  the  paroxysms  con- 
tinued to  recur  simultaneously  after  delivery.  The  foetus  has  also  been 
born  with  distinct  malarious  enlargement  of  the  sj)leen.  From  the  fre- 
quency with  which  largely  hypertrophied  spleens  are  seen  in  mere  infants 
in  malarious  districts,  I  imagine  that  the  intra-uterine  disease  must  be 
common.  I  have  frequently  observed  this  fact  in  India,  although,  of 
course,  without  any  possibility  of  ascertaining  if  the  mothers  had  suf- 
fered from  intermittent  fever  during  pregnancy.  Lead-poisoning  is  also 
known  to  have  a  most  prejudicial  effect  on  the  foetus,  and  frequently  to 
lead  to  abortion.  M.  Paul  has  collected  81  cases  ^  in  which  it  caused 
the  death  of  the  foetus,  in  some  not  until  after  birth  ;  and  occasionally  it 
seems  to  have  affected  the  foetus  even  when  the  mother  escaped. 

Syphilis. — Of  all  blood-clyscrasise  transmitted  to  the  foetus,  the  most 
important  is  syphilis.  Its  influence  in  producing  repeated  abortion  will 
be  elsewhere  described  (p.  247).  It  may  unquestionably  be  transmit- 
ted to  the  foetus  without  producing  abortion,  and  at  term  the  mother 
may  be  either  delivered  of  a  living  child  bearing  evident  traces  of  the 
disease,  of  a  dead  child  similarly  affected,  or  of  an  apparently  healthy 
child  in  whom  the  disease  develops  itself  after  a  lapse  of  a  month  or 
two.  These  varying  effects  probably  depend  on  the  intensity  of  the 
poison  ;  and  the  longer  the  time  that  has  elapsed  since  the  origin  of  the 

^  Arch.  (/en.  de  Med.,  1860. 


PATHOLOGY  OF  THE  DEGIDUA   AND   OVUM.  239 

disease  in  the  affected  parents,  the  better  will  be  the  chance  for  the  child. 
The  disease  is  no  doubt  generally  transmitted  through  the  mother,  and 
if  she  be  affected  at  the  time  of  conception,  the  infection  of  the  foetus 
seems  certain.  If,  however,  she  contracts  the  disease  at  an  advanced 
period  of  pregnancy,  the  child  may  entirely  escape.  Ricord  even  believes 
that  syphilis,  contracted  after  the  sixth  month  of  pregnancy,  never  affects 
the  child.  The  father  alone  may  transmit  the  disease  to  the  ovum  ;  and 
Hutchinson  has  recorded  cases  to  show  that  the  mother  may  become  sec- 
ondarily  affected  through  the  diseased  foetus.  The  evidences  of  syphil-  ( 
itic  taint  in  a  living  or  dead  child  are  sufficiently  characteristic.  The  j 
child  is  generally  puny  and  ill-developed.  An  eruption  of  pemphigus  \ 
is  common,  either  fully  developed  bullse  or  their  early  stage,  when  they 
form  circular  copper-colored  patches.  This  eruption  is  always  most 
marked  on  the  hands  and  feet,  and  a  child  born  with  such  an  eruption 
may  be  certainly  considered  syphilitic.  On  post-mortem  examination 
the  most  usual  signs  are  small  patches  of  suppuration  in  the  thymus, 
similar  localized  suppurations  in  the  tissues  of  the  lungs,  indurated  yel- 
lowish patches  in  the  liver,  and  peritonitis,  the  importance  of  which  in 
causing  the  death  of  syphilitic  children  has  been  specially  dwelt  on  by 
Simpson.^ 

Lrfimnmatmiy.  Diseases. — The  most  important  of  the  inflammatory  ^ 
diseases  affecting  the  foetus  is  peritonitis.  Simpson  has  shown  that  traces  s j 
of  it  are  very  frequently  met  with,  and  that  it  is  not  always  syphilitic. 
Sometimes  it  has  been  observed  when  the  mother  has  been  in  bad  health 
during  pregnancy,  and  at  others  it  seems  to  have  resulted  from  some 
morbid  condition  of  the  foetal  viscera.  Pleurisy  with  effusion  is  another 
inflammatory  affection  which  has  been  noticed.  _ 

Dropsies. — The  dropsical  affections  most  generally  met  with  are  ascites       j 
and  hydrocephalus,  which  may  both  have  the  effect  of  impeding  delivery,    /tl 
Of  these,  hyjiroceplialus  is  tlie  more  common,  and  may  give  rise  to  much  >-^ 
difficulty  in  labor.     Its  causes  are  uncertain,  but  it  probably  depends  on 
some  altered  state  of  the  mother's  health,  as  it  is  apt  to  recur  in  several 
successive  pregnancies,  and  is  not  infrequently  associated  with  an  imper- 
fectly developed  vertebral  column  and  spina  bifida.     The  fluid  collects 
in  the  ventricles,  which  it  greatly  distends,  and  these  then  produce  expan- 
sion and  thinning  of  the  cranium,  the  bones  of  which  are  widely  sepa- 
rated from  each  other  at  the  sutures,  which  are  prominent  and  fluctuat-  . 
ing.     In  a  few  cases  internal  hydrocephalus  may  be  complicated,  and  ^ 
the  diagnosis  in  labor  consequently  obscured  by  the  coexistence  of  what 
has  been  called  "  external  hydrocephalus."    This  consists  of  a  collection 
of  fluid  ])etvveen  the  skull  and  the  scalp,  which  may  be  either  formed 
there  originally  or  may  collect  from  a  rupture  of  one  of  the  sutures  or 
fontanellcs  during  labor,  through  which  the  intracranial  fluid  escapes. 

Ascites  is  generally  associated  with  hydramnios,  and  sometimes  with  j 
hydrotliorax  or  other  dropsical  effusions.     It  is  a  rare  afl'ection,  and 
acc()rdiiig  to  DcpauP  extreme  distension  of  the  bladder  is  not  infre-  ' 
quontly  mistaken  for  it. 

Tumors. — Tumors  of  different  kinds  may  be  met  with  in  various  parts 
of  the  child's  body,  whicli  sometimes  grow  to  a  great  size  and  impede 

'  Oljs/.  Ifor/.v,  vol.  i.  p.  117.  ^  Turnier'.s  Oazmiu;  p.  855. 


-1 


240 


PREG^\iycY 


delivery.  Tarnier  records  cases  of  meningocele  larger  than  a  child's 
head,  and  large  cystic  growths  have  been  observed  attached  to  the  nates, 
pectoral  region,  or  other  parts  of  the  body.  Cancerous  tumors  of  con- 
siderable size,  either  external  or  of  the  viscera,  have  also  been  met  with. 
Other  foetal  tumors  may  be  produced  by  congenital  deformities,  such  as 
projection  of  the  liver  or  other  abdominal  viscera  through  a  deficiency 
of  the  abdominal  wall ;  or  spina  bifida  from  imperfectly  developed  verte- 
brae. The  amount  of  dystocia  produced  by  such  causes  wall,  of  course,  vary 
much  in  proportion  to  the  size,  consistency,  and  accessibility  of  the  tumor. 
Wounds  and  Injuries  of  the  Foetus. — Accidents  of  serious  gravity  to 
the  foetus  may  happen  from  violence  to  which  the  mother  has  been  sub- 
jected, such  as  falls  or  blows,  without  necessarily  interfering  with  gesta- 
tion. Many  curious  examples  of  this  kind  are  on  record.  Thus,  a  child 
has  been  born  presenting  a  severe  lacerated  w^ound  extending  the  whole 
length  of  the  sj^ine,  where  both  the  skin  and  the  muscles  had  been  torn, 
and  which  seems  to  have  resulted  from  the  mother  having  fallen  in  the 
last  month  of  pregnancy.  Similar  lacerations  and  contusions  have  been 
observ^ecl  in  other  parts  of  the  body,  the  wounds  being  in  various  stages 
of  cicatrization  corresponding  to  the  lapse  of  time  since  the  accident  had 
occurred.  Intra-uterine  fractures  are  not  rare,  apparently  arising  from 
similar  causes.  In  some  of  these  cases  the  broken  ends  of  the  bones 
had  united,  but,  from  want  of  accurate  apposition,  at  an  acute  angle,  so 
as  to  give  rise  to  much  subsequent  deformity.  Chaussier  records  two 
cases  in  which  there  were  many  fractures  in  the  same  child,  in  one  113 
and  in  another  42,  which  were  in  cliiferent  stages  of  repair.  He  attrib- 
utes this  curious  occurrence  to  some  congenital  defect  in  the  nutrition  of 
the  bones,  possibly  allied  to  mollities  ossium.^ 

Intra-uterine  Amputations  of  Foetal  Limbs. — Intra-uterine  amputa- 
tions of  foetal  limbs  have  not  unfrequently  been  observed.     Children 

are  occasionally  born  wdth  one  extremity  more 
or  less  completely  absent,  and  cases  are  known 
in  which  the  whole  four  extremities  were  want- 
ing (Fig.  93).  The  mode  in  which  these  mal- 
formations are  produced  has  given  rise  to  much 
discussion.  At  one  time  it  was  supposed  that 
the  deficiency  of  the  limb  was  due  to  gangrene 
of  the  extremity  and  subsequent  separation  of 
the  sphacelated  parts.  Reuss,  ^svho  has  studied 
the  whole  subject  very  minutely,^  considers 
gangrene  in  the  unruptured  ovum  to  be  an 
impossibility,  for  that  change  cannot  occur 
unless  there  is  access  of  oxygen,  and  when 
portions  of  the  separated  extremity  are  found 
in  utero,  as  is  often  the  case,  they  shoAV  evi- 
dences of  maceration,  but  not  of  decomposi- 
tion. The  general  belief  is  that  these  intra- 
intra-uterine  Amputation  of      uterine  amputations  depend  on  constriction  of 

iDOth  Arms  and  Legs.  i  •     i     i        p  i  i  i         i         <?  j^i 

the  imib  by  lolds  or  bands  oi  the  amnion — 
most  often  met  with  when  the  liquor  amnii  is  deficient  in  quantity — 


Fig.  93. 


Oazetfe  hebdom.,  1860. 


^  Scanzoni's  Beiirdge,  1869. 


PATHOLOGY  OF  THE  DECTDUA   AND   OVUM.  241 

which  obstruct  the  circulation  and  thus  give  rise  to  atrophy  of  the  part 
below  the  constriction.  It  has  been  supposed  that  the  umbilical  cord 
might,  by  encircling  the  limb,  produce  a  like  result.  It  appears  doubt- 
ful, however,  whether  this  cause  is  sufficient  to  produce  complete  sepa- 
ration of  the  limb,  as  any  great  amount  of  constriction  would  intertere 
with  the  circulation  through  the  cord.  Sometimes,  when  intra-uterine 
amputation  occurs,  the  separated  portion  of  the  limb  is  found  lying  loose 
in  the  amniotic  cavity,  and  is  expelled  after  the  child.  Cases  of  this 
kind  have  been  recorded  by  Martin,  Chaussier,  and  Watkinson.  More 
often  no  trace  of  the  separated  extremity  can  be  found.  The  explana- 
tion probably  depends  upon  the  period  of  utero-gestation  at  which  ampu- 
tation took  place.  If  it  occurred  at  a  very  early  period  of  pregnancy, 
before  the  third  month,  the  detached  portion  would  be  minute  and  soft, 
and  would  easily  disappear  by  solution.  If  at  a  later  period,  this  could 
hardly  happen,  and  the  detached  portion  would  remain  in  utero.  In 
cases  of  the  latter  kind  cicatrization  of  the  stump  has  often  been  observed 
to  be  incomplete.  Simpson  pointed  out  the  occasional  existence  of  rudi- 
mentary fingers  or  toes  on  the  stump  of  an  amputated  limb,  such  as  are 
seen  on  the  thighs  in  Fig.  93.  These  he  attributed  to  an  abortive  repro- 
duction of  the  separated  extremity,  analogous  to  what  is  observed  in 
some  of  the  lower  animals.  This  explanation  has  been  contested  with 
much  show  of  reason.  Martin  believes  that  the  reproduction  is  only 
apparent,  and  that  the  rudimentaiy  extremities  are,  in  reality,  instances 
of  arrested  development.  The  constricting  agents  interfered  with  the 
circulation  sufficiently  to  arrest  the  growth  of  the  limb  below  the  site 
of  constriction,  but  not  sufficiently  to  effect  complete  separation.  If 
constriction  occurred  at  a  very  early  stage  of  development,  an  appear- 
ance similar  to  that  observed  by  SimjDson  would  be  produced.  It  does 
not  follow,  however,  that  all  cases  of  absence  of  limbs  depend  on  intra- 
uterine amputations.  In  some  cases  they  would  appear  to  be  the  result 
of  a  spontaneous  arrest  of  development  or  of  congenital  monstrosity. 
Mr.  Scott  ^  relates  a  case  in  which  a  distinct  hereditary  tendency  was 
evident,  and  here  the  deformity  certainly  could  not  have  resulted  from 
the  constriction  of  amniotic  bands.  In  this  family  the  grandfather  had 
both  forearms  wanting,  with  rudimentary  fingers  attached ;  the  next 
generation  escaped,  but  the  grandchild  had  a  deformity  precisely  similar 
to  the  grandfather. 

Death  of  Foetus. — When  from  any  cause  the  foetus  has  died  during 
pregnancy,  it  may  be  either  soon  expelled  or  it  may  be  retained  in  utero 
for  a  longer  or  shorter  time,  or  even  to  the  full  period.  The  changes 
observed  in  sucli  foetuses  vary  considerably  according  to  the  age  of  the 
ffjetus  at  the  time  of  death  or  the  time  that  it  has  been  retained  in  utero. 
If  it  die  at  an  early  period,  when  the  tissues  are  very  soft,  it  may  entirely 
dissolve  in  the  liquor  amnii,  and  no  trace  of  it  may  be  found  when  the 
membranes  are  expelled.  Or  it  may  shrivel  or  mummify;  and  if  this 
happen  in  a  twin  pregnancy,  as  sometimes  occurs,  the  growing  foetus  may  i 
compress  and  flatten  the  dead  one  against  the  uterine  wall. 

Appearance  of  a  Putrid  Fvetm. — At  a  later  ])eriod  of  pregnancy  a 
dead  foetus  undergoes  changes  ascribed  to  putrefaction,  but  which  })ro- 

'  Ohnl.  Tranx.,  vol.  xiii.  p.  !)4. 


242  PREGNANCY. 

duce  appearances  diiferent  from  those  of  decomposition  in  animal  textures 
exposed  to  the  atmosphere.  There  is  no  offensive  smell,  as  in  ordinary 
decay.  The  tissues  are  all  softened  and  flaccid.  The  more  manifest 
changes  are  in  the  skin,  the  epidermis  of  ^vhich  is  separated  from  the 
cutis  vera,  which  has  a  deep  reddish  color.  This  is  especially  apparent 
on  the  abdomen,  which  is  flaccid  and  hollow  in  the  centre.  The  internal 
organs  are  much  altered.  The  brain  is  diffluent  and  pulpy,  and  the 
cranial  bones  loose  within  the  scalp.  The  structures  of  the  muscles  and 
viscera  are  in  various  stages  of  transformation,  many  having  undergone 
fatty  changes,  and  contain  crystals  of  margarin  and  cholesterin.  Tlie 
extent  to  which  these  changes  occur  depends,  in  a  great  measure,  on  the 
length  of  time  the  foetus  has  been  dead,  but  they  do  not  admit  of  our 
estimating  with  any  degree  of  accuracy  wdiat  that  time  has  been. 

Symptoms  and  Diagnosis  of  the  Death  of  the  Foetus. — The  symptoms 
and  diagnosis  of  the  death  of  the  foetus  may  here  be  considered.  They 
are,  unfortunately,  not  very  reliable.  The  cessation  of  the  fcetal  move- 
ments cannot  be  depended  on,  as  they  are  frequently  unfelt  for  days  or 
weeks  when  the  child  is  alive  and  well.  Sometimes  the  death  of  the 
foetus  is  preceded  by  its  irregular  and  tumultuous  movements,  and  in 
women  who  have  been  delivered  of  several  dead  children  in  succession 
this  sensation  may  guide  us  in  our  diagnosis.  This  suspicion  may  be 
confirmed  by  auscultation.  The  mere  fact  that  we  are  unable,  at  any 
given  time,  "to  hear  the  foetal  heart  will  not  justify  an  opinion  that  the 
foetus  is  dead.  If,  however,  the  foetal  heart  has  been  distinctly  heard, 
and  after  one  or  two  careful  examinations,  repeated  at  separate  times,  it 
cannot  again  be  made  out,  the  probability  of  the  child  being  dead  may 
be  assumed.  Certain  changes  in  the  mother's  health  have  been  noted  in 
connection  with  the  death  of  the  foetus,  such  as  depression  and  lowness 
of  spirits,  a  feeling  of  coldness  and  weight  about  the  lower  parts  of  the 
abdomen,  paleness  of  the  face,  a  livid  circle  round  the  eyes,  irregular 
shiverings  and  feverishness,  shrinking  of  the  breasts,  and  diminution  in 
the  size  of  the  abdominal  tumor.  All  these,  however,  are  too  indefinite 
to  justify  a  positive  diagnosis,  and  they  are  not  infrequently  altogether 
absent.  At  most  they  can  do  no  more  than  cause  a  suspicion  as  to  what 
has  happened. 


CHAPTEK   X. 

ABOETION   AND   PREMATUEE  LABOR. 

Importance  and  Frequency  of  Abortion. — The  premature  expulsion  of 
the  foetus  is  an  event  of  great  frequency.  The  number  of  foetal  lives 
thus  lost  is  enormous.  There  are  few  multiparse  who  have  not  aborted 
at  one  time  or  other  of  their  lives.  Hegar  estimates  that  about  1  abor- 
tion occurs  to  every  8  or  10  deliveries  at  term.     Whitehead  has  calcu- 


ABORTION  AND  PREMATURE  LABOR.  243 

lated  that  at  least  90  per  cent,  of  married  women  who  Kved  to  the  change 
of  life  had  aborted.  The  influence  of  this  incident  on  the  future  health 
of  the  mother  is  also  of  great  importance.  It  rarely,  indeed,  proves 
directly  fatal,  but  it  often  produces  great  debility  from  the  profuse  loss 
of  blood  accompanying  it ;  and  it  is  one  of  the  most  prolific  causes  of 
uterine  disease  in  after-life,  possibly  because  women  are  apt  to  be  more 
careless  during  convalescence  than  after  delivery,  and  the  proper  invo- 
lution of  the  uterus  is  thus  more  frequently  interfered  with. 

Definition. — A  not  uncommon  division  of  the  subject  is  into  abortion, 
miscarriage,  and  premature  labor,  the  first  name  being  applied  to  expul- 
sion of  the  ovum  before  the  end  of  the  fourth  month  of  utero-gestation ; 
miscarriage,  to  expulsion  from  the  end  of  the  fourth  to  the  end  of  the 
sixth  month ;  and  premature  labor,  to  expulsion  from  the  end  of  the 
sixth  month  to  the  term  of  pregnancy.  This  is,  however,  a  needless  and 
confusing  subdivision,  which  leads  to  no  practical  result.  It  suffices  to 
apply  the  term  abortion  or  miscarriage  indiscriminately  to  all  cases  in 
which  pregnancy  is  terminated  before  the  foetus  has  arrived  at  a  viable 
age,  and  premature  labor  to  those  in  which  there  is  a  possibility  of  its 
survival.  There  is  little  or  no  hope  of  a  foetus  living  before  the  28th 
week  or  seventh  lunar  month,  and  this  period  is  therefore  generally  fixed 
on  as  the  limit  between  premature  labor  and  abortion.  The  rule  is, 
however,  not  without  an  occasional,  although  very  rare,  exception.  Dr. 
Keiller  of  Edinburgh  has  recorded  an  instance  in  which  a  foetus  was 
born  alive  at  the  fourth  month,  nine  days  after  the  mother  had  experi- 
enced the  sensation  of  quickening.  I  myself  recently  attended  a  lady 
who  miscarried  in  the  fifth  month  of  pregnancy,  the  child  being  born  alive 
and  living  for  three  hours.  Several  cases  are  on  record  in  which  after 
delivery  in  the  sixth  month  the  child  survived  and  was  reared.  The 
possibility  of  the  birth  of  a  living  child  under  such  circumstances  should 
be  recognized,  as  it  may  give  rise  to  legal  questions  of  importance ;  but 
the  exceptions  to  the  ordinary  rule  are  so  rare  that  they  need  not  interfere 
with  the  division  of  the  subject  usually  made. 

Abortion  is  most  Common  in  Multiparm. — Multiparse  abort  far  more 
fre(piently  than  primiparse.  This  is  contrary  to  the  statement  in  many 
obstetrical  works.  Thus,  Tyler  Smith  says  "  there  seems  to  be  a  greater, 
danger  of  this  accident  in  the  first  pregnancy."  Schroeder,^  however, 
states  that  23  multiparffi  abort  to  3  primiparse ;  and  Dr.  "Whitehead  of 
Manchester,  ^x\\o  has  particularly  studied  the  subject,  believes  that  abor- 
tion is  more  apt  to  occur  after  the  third  and  fourth  pregnancies,  espe- 
cially when  these  take  ])lace  t(jvv-ard  the  tiiiie  for  the  cessation  of  men- 
struation. 

Liability  to  a  Recurrence  of  Abort'tov. — Tliere  can  be  no  doubt  that 
women  who  have  aborted  more  than  on(*e  are  ])ecnliarly  liable  to  a 
re(;urr(!iu;e  of  th(!  actudcnt.  This  can  generally  be  traced  to  the  exist- 
ence; of  some  pre(lis])osing  cniise  which  j)ersists  through  several  pregnan- 
ci(;s,  as,  for  <'xam|)l(',  a  syphilitic  taint,  a  uteriiu;  flexion,  or  a  morbid 
state  of  the  lining  m(;nibran(M)f  the  uterns.  It  is  ])robable  that  in  many 
vvoMien  a  recurrence  of  the  a('(;ident  in(hices  a  habit  of  abortion,  or  per- 
haps it  miglit  be  more  a(!(!urate  to  say  a  petiidiar  irritable  condition  of 

'  S(liroo<I(;r,  ManiKil  of  Midwifery,  p.  149. 


244  PREGNANCY. 

the  uterus,  which  renders  the  continuance  of  pregnancy  a  matter  of  cliffi- 
cuhy,  independently  of  any  recognizable  organic  cause. 

Very  Early  Abortions  are  often  Unrecognized. — The  frequency  of 
abortion  varies  much  at  different  periods  of  pregnancy  ;  and  it  occurs 
much  more  often  in  the  early  months,  because  of  the  comparativel}' 
slight  connection  then  existing  between  the  chorion  and  the  decidua. 
At  a  very  early  period  of  pregnancy  the  ovum  is  cast  off  with  such  facil- 
ity, and  is  of  such  minute  size,  that  the  fact  of  abortion  having  occurred 
passes  um'ecognized.  Very  many  cases  in  which  the  patient  goes  one 
or  two  weeks  over  her  time,  and  then  has  what  is  supposed  to  be  merely 
a  more  than  usually  profuse  period,  are  probably  instances  of  such  early 
miscarriages.  Velpeau  detected  an  ovum  of  about  fourteen  days  whicli 
was  not  larger  than  an  ordinary  pea ;  and  it  is  easy  to  understand  how 
so  small  a  body  should  pass  unnoticed  in  the  blood  Avhich  escapes  along 
with  it. 

Before  the  End  of  the  Third  Month  the  Ovum  is  generally  Expelled 
Entire. — Up  to  the  end  of  the  third  month,  when  miscarriage  occurs,  the 
ovum  is  generally  cast  off  en  masse,  the  decidua  subsequently  coming 
away  in  shreds  or  as  an  entire  membrane.  The  abortion  is  then  com- 
paratively easy.  From  the  third  to  the  sixth  month,  after  the  placenta 
is  formed,  the  amnion  is,  as  a  rule,  first  ru])tured  by  the  uterine  contrac- 
tions, and  the  foetus  is  expelled  by  itself.  The  j)lacenta  and  membranes 
may  then  be  shed  as  in  ordinary  labor.  It  often  happens,  however,  that 
on  account  of  the  firmness  of  the  placental  adhesion  at  this  period  the 
secundines  are  retained  for  a  greater  or  less  length  of  time.  This  sub- 
jects the  patient  to  many  risks,  especially  to  those  of  profuse  hemor- 
rhage and  of  septicsemia.  For  this  reason,  premature  termination  of  the 
pregnancy  is  attended  by  much  greater  danger  to  the  mother  between 
the  third  and  sixth  months  than  at  an  earlier  or  later  date.  After  the 
sixth  month  the  course  of  events  is  not  different  from  that  attending 
ordinary  labor.  The  prognosis  to  the  child  is  more  unfavorable  in  pro- 
portion to  the  distance  from  the  full  period  of  gestation  at  which  pre- 
mature labor  takes  place. 

Causes. — The  causes  of  abortion  may  conveniently  be  subdivided  intc 
,  the  predisposing  and  exciting,  the  latter  being  often  slight,  and  such  as 
would  have  no  effect  in  inducing  uterine  contractions  in  women  unless 
'  associated  'SA'ith  one  or  more  of  the  former  class  of  causes.  The  predis- 
position to  abortion  may  depend  on  some  condition  interfering  with  the 
vitality  of  the  ovum  or  its  relation  to  the  maternal  structures,  or  on  cei  - 
tain  conditions  directly  affecting  the  mother's  health. 

CoMses  B-eferable  to  the  Foetus. — One  of  the  most  common  antecedents 
of  abortion  is  the  death  of  the  foetus,  which  leads  to  secondary  changes, 
and  ultimately  produces  the  uterine  contractions  which  end  in  its  expul- 
sion. The  precise  causes  of  death  in  any  given  case  cannot  always  be 
accurately  ascertained,  as  they  sometimes  depend  on  conditions  which 
are  traceable  to  the  maternal  structures,  at  others  to  the  ovular,  or  it 
may  be  to  a  combination  of  the  two.  Nor  does  it  by  any  means  follow 
that  the  death  of  the  ovum  immediately  results  in  its  expulsion.  The 
mode  in  which  death  of  the  ovum  produces  abortion  is  not  difficult  tu 
understand,  for  it  necessarily  leads  to  changes  in  the  relations  between 


ABORTION  AND  PREMATURE  LABOR. 


245 


the  ovular  and  maternal  structures ;  these  changes  cause  hemorrhages — 
partly  external  and  partly  into  the  membranes — which  in  their  turn 
excite  uterine  contraction.  Extravasations  of  blood  may  take  place  in  wCi,vv-> 
various  positions.  One  of  the  most  common  is  into  the  decidual  cavity,  /^J^;^ 
between  the  decidua  vera  and  the  decidua  reflexa,  or  between  the  decidua 
vera  and  the  uterine  walls.  If  the  hemorrhage  is  only  slight,  and  espe- 
cially if  it  comes  from  that  portion  of  the  decidua  near  the  internal  os 
and  at  a  distance  from  the  ovum,  there  need  be  no  material  separation, 
and  pregnancy  may  continue.  This  explains  the  cases  occasionally  met 
with  in  which  there  is  more  or  less  hemorrhage  without  subsequent 
abortion.  When  the  amount  of  extra vasated  blood  is  at  all  great,  sepa- 
ration and  abortion  necessarily  result,  and  the  decidua  will  be  found  on 
expulsion  to  have  coagula  on  its  surface  and  between  its  various  layers 
which  are  found  to  project  into  the  cavity  of  the  amnion  (Fig.  94).     In 

Fig.  94. 


An  Apoplectic  Ovum,  with  Blood  effused  in  masses  under  the  Fcetal  Surface  of  the  Membranes. 

other  cases  hemorrhage  is  still  more  extensive,  and,  after  breaking 
through  the  decidua  reflexa,  it  forms  clots  between  it  and  the  chorion, 
and  even  in  the  cavity  of  the  amnion.  Supposing  expulsion  to  take 
place  shortly  after  coagula  are  deposited  among  the  membranes,  the 
blood  is  little  altered,  and  we  have  an  ordinary  abortion.  If,  however, 
the  ovum  is  retained,  the  coagulated  fibrin  and  the  placenta  or  mera- 
l>ranes  undergo  secondary  changes  which  lead  to  the  formation  of  moles. 
The  so-called  fl<i>ihy  mole  (Fig.  95)  is  often  retained  for  many  weeks  or 
months  after  the  death  of  the  fjotus,  and  during  this  time  there  may  be 
but  little  modification  of  the  usual  symptoms  of  pregnancy ;  or,  as  is 
fref|uently  the  case,  it  gives  rise  to  occasional  hemorrhage,  until  at  last 
uterine  contractions  come  on,  and  it  is  cast  off  in  the  form  of  a  thick 
fleshy  ma.ss,  having  but   little  resemblance  to  the  ordinary  products  of 


246 


PREGNANCY. 


conception.  The  most  probable  explanation  of  its  formation  is,  that 
when  hemorrhage  originally  took  place  the  effnsion  of  blood  was  not 
sufficient  to  effect  the  entire  separation  and  expulsion  of  the  ovum. 
Part  of  the  membranes  or  of  the  placenta — if  that  organ  had  commenced 
to  form — retained  its  organic  connection  with  the  uterus,  while  the  foetus 


Blighted  Ovum,  with  Fleshy  Degeneration  of  the  Membranes. 

perished.  The  attached  portion  of  the  placenta  or  membranes  continues 
to  be  nourished,  although  abnormally.  The  foetus  generally  entirely 
disappears,  especially  if  it  has  perished  at  an  early  period  of  utero-gesta- 
tion,  when  it  becomes  dissolved  in  the  liquor  amnii.  Or  it  may  become 
macerated,  shrivelled,  and  greatly  altered  in  appearance.  The  effused 
blood  becomes  decolorized  from  the  absorption  of  the  corpuscles,  and, 
according  to  Scanzoni,  fresh  vessels  are  developed  in  the  fibrin,  which 
increase  the  vascular  attachment  of  the  mole  to  the  uterine  walls.  The 
placenta  and  membranes  may  go  on  increasing  in  thickness  until  they 
form  a  mass  of  considerable  size.  Careful  microscopic  examination  will 
almost  always  enable  us  to  discover  the  villi  of  the  chorion,  altered  in 
appearance,  often  loaded  with  granular  fatty  molecules,  but  sufficiently 
distinct  to  be  readily  recognizable. 

Causk  depending  on  the  Maternal  State. — Important  as  are  the  causes 
of  abortion  arising  from  some  morbid  condition  of  the  ovum,  they  are 
not  more  so  than  those  which  depend  on  the  maternal  state,  and  it  is  to 
be  observed  that  the  former  are  often  indirect  causes,  produced  by  ])ri- 
mary  maternal  changes.  Many  of  these  maternal  causes  act  by  causing 
hyperjemia  of  the  uterus,  which  leads  to  extravasation  of  blood.  Thus, 
abortion  is  apt  to  occur  in  women  who  lead  unhealthy  lives,  sucli  as 
those  who  occupy  overheated  and  ill-ventilated  rooms  or  indulge  to 
excess  in  the  fatigues  and  pleasures  of  society,  in  the  use  of  alcoholic 
drinks,  and  the  like.  Over-frequent  coitus  has  been,  for  the  same  rea- 
son, observed  to  produce  a  remarkable  tendency  to  abortion,  and  Parent- 


ABORTION  AND  PREMATURE  LABOR.  247 

Duchatelet  has  noted  that  it  is  of*  very  frequent  occurrence  amongst 
women  of  loose  life.     Many  diseases  strongly  predispose  to  it,  such  as  ' 
fevers,  zymotic  diseases  of  all  kinds,  measles,  scarlet  fever,  small-pox ;  ' 
and  diseases  of  the  respiratory  organs,  such  as  bronchitis  and  pneu- 
monia.    Syphilis  is  well  known  to  be  one  of  the  most  frequent  causes, 
and  one  that  is  likely  to  act  in  successive  pregnancies.     It  may  act  S(j 
that  the  pregnancy  is  brought  to  a  premature  termination,  time  after 
time,  until  the  constitutional  disease  is  eradicated  by  appro]3riate  treat- 
ment.    It  acts  in  some  cases  through  the  influence  of  the  father  in  pro-  | 
ducing  a  diseased  ovum,  and  it  is  the  only  cause  which  can  with  certainty 
be  traced  to  the  state  of  the  father's  health.     Many  other  morbid  condi- 
tions of  the  blood  also  dispose  to  abortion.     It  has  been  observed  to  be 
a  frequent  result  of  lead-poisoning ;  also  of  the  presence  of  noxious  gases 
in  the  atmosphere,  such  as  an  excess  of  carbonic  acid. 

Cames^acting  through  the^  Nervous  System. — Many  causes  act  through 
the  nervous  system,  such  as  fright,  anxiety,  sudden  shock,  and  the  like. 
Thus,  there  are  numerous  instances  on  record  in  which  women  aborted 
suddenly  after  the  receipt  of  some  bad  news,  and  it  is  said  to  have  been 
of  frequent  occurrence  in  women  immediately  before  execution.  The 
influence  of  irritation  propagated  through  the  nervous  system  from  a 
distance,  tending  to  produce  uterine  contraction  and  abortion  through 
the  agency  of  reflex  action,  has  been  specially  dwelt  upon  by  Tyler 
Smith.  Thus  he  points  out  that  abortion  not  unfrequently  occurs  from  1 
the  irritation  of  constant  suckling  in  women  who  become  pregnant ' 
during  lactation.  The  effect  of  suckling  in  producing  uterine  con- 
traction is  indeed  well  known,  and  the  application  of  the  child  to  the 
breast  for  this  purpose  has  long  been  recognized  as  a  method  of  treat- 
ment in  post-partum  hemorrhage.  The  irritation  of  the  trifacial  in 
severe  toothache,  of  the  renal  nerves  in  cases  of  gravel,  in  albuminuria, 
etc.,  of  the  intestinal  nerves  in  excessive  vomiting,  in  diarrhoea,  obsti- 
nate constipation,  ascarides,  etc.,  all  act  in  the  same  way.  We  may 
perhaps  also  explain  by  this  hypothesis  the  fact  that  women  are  more 
apt  to  abort  at  what  would  have  been  the  menstrual  epoch  than  at  other 
times,  as  the  ovarian  nerves  may  then  be  subject  to  undue  excitement. 
It  is  probable,  however,  that  there  may  be  also  at  these  times  more  or 
less  active  congestion  of  the  decidua,  which  may  predispose  to  laceration 
of  its  capillaries  and  blood-extravasation.  Such  congestion  exists  in 
those  exceptional  cases  in  which  menstruation  continues  for  one  or  more 
periods  after  conception,  the  blood  probably  escaping  from  the  space 
between  the  decidua  vera  and  reflexa ;  and  therefore  there  is  no  reason 
to  question  its  also  happening  even  M'hen  such  abnormal  menstruation  is 
not  present. 

FliysiealJJauHes. — Certain  physical  causes  may  produce  abortion  b}- 
separating  the  ovum.  Thus  it  may  follow  a  fall,  a  blow,  or  other 
acfridents  of  a  trivial  character.  On  the  otlier  hand,  women  may  be 
subjected  to  injuries  of  the  severest  kind  without  aborting.  The  prob- 
abihty,  therefjre,  is  that  these  appai'cntly  trivial  causes  only  operate;  in 
woniJ-n  who  for  some  other  reason  are  j)re(lisp(jsed  to  the  accident.  Tliis 
is  borne  out  by  the  fact — which  is  well  known  in  these  days,  when  the 
artificial   production   of  abortion   is,  unhappily,  far  from   a  very  rare 


248  PREGNANCY. 

event — that  it  is  by  no  means  easy<to  destroy  the  vitality  of  the  foetus. 
I  myself  know  of  a  case  in  which  the  uterine  sound  was  passed  several 
times  into  a  pregnant  uterus  without  producing  abortion,  the  pregnancy 
proceeding  to  term.  Oldham  has  related  a  similar  case  in  which  he  in 
vain  attempted  to  produce  abortion  by  the  sound  in  a  case  of  contracted 
pelvis ;  and  Duncan  has  mentioned  an  instance  in  which  an  intra-uterine 
stem  pessary  was  unwittingly  introduced,  and  worn  for  some  time  by  a 
pregnant  woman,  without  any  bad  effect.  The  fact  that  pregnancy  is 
with  difficulty  interfered  with  when  there  is  a  healthy  relation  between 
the  ovum  and  the  uterus  no  doubt  explains  the  disastrous  effects  of 
criminal  abortion  which  have  been  especially  insisted  on  by  many  of  our 
American  brethren. 

Cases  depending  on  Morbid  States  of  the  Uterus. — Morbid  states  of 
the  uterus  have  an  important  influence  in  the  production  of  abortion. 
j  Any  condition  Mdiich  mechanically  interferes  with  the  proper  develop- 
ment  of  the  uterus  is  apt  to  operate  in  this  way.     Amongst  these  may 
[  be  mentioned  fibroid  tumors ;  the  presence  of  old  peritoneal  adhesions, 
)  rendering  the  womb  a  more  or  less  fixed  organ ;  but,  above  all,  flexion 
I  and  displacement  of  the  uterus.     Retroflexion  of  the  uterus  is  unques- 
j  tionably  one  of  the  most  frequent  factors  in  its  production,  not  only  on 
'  account  of  the  irritation  which  the  abnormal  position  sets  up,  but  from 
'  interference  with  the  uterine  circulation,  which  leads  to  the  effusion  of 
';  blood  and  the  death  of  the  ovum.    An  inflamed  condition  of  the  cervical 
and  uterine  mucous  membranes  will  act  in  the  same  way  should  preg- 
nancy have  occurred,  although  such  a  condition  more  often  prevents 
conception  taking  place. 

Symptoms. — One  of  the  earliest  indications  of  impending  abortion  is 
t-n        more  or  less  hemorrhage.     This  may  at  first  be  slight,  and  may  last  for 
""""      a  short  time  only,  recurring  after  an  interval  of  time,  or  it  may  com- 
mence with  a  sudden  and  profuse  discharge.     Occasionally  it  is  very 
abundant,  and  its  continuance  and  amount  form  one  of  the  gravest 
symptoms  of  the  accident.     After  the  loss  of  blood  has  continued  for 
a  greater  or  less  length  of  time — it  may  be  even  for  some  days — uterine 
jj^^^jjcontractions  come  on,  recurring  at  regular  intervals,  and  eventually  lead 
■— ~     to  the  expulsion  of  the  ovum.     More  rarely  the  impending  miscarriage 
commences  with  pains  which  lead  to  laceration  of  vessels  and  hemor- 
rhage. 

When  Pain  and  Hemorrhage  Coexist. — As  long  as  one  or  other  of 
these  symptoms  exist  alone  we  may  hope  to  avert  the  threatened  mis- 
carriage, but  when  both  occur  together  there  is  little  or  no  chance  of  its 
being  arrested.  Certain  premonitory  symptoms  are  described  by  authors 
as  common  in  abortion,  such  as  feverishness,  shivering,  a  sensation  of 
coldness ;  all  of  which  are  obscure  and  unreliable,  and  are  certainly 
much  more  frequently  absent  than  present. 

If  the  pregnancy  be  early,  it  is  probable  that  the  entire  ovum  will  be 
shed  Avith  little  trouble,  and  it  often  passes  unperceived  in  the  clots 
which  surround  it.  It  is  therefore  of  importance  that  all  the  discharges 
should  be  very  carefully  examined.  After  the  second  month  the  rigid 
and  undilated  cervix  presents  a  formidable  obstacle  to  the  escape  of  the 
ovum,  and  it  may  be  a  considerable  time  before  there  is  sufficient  dilata- 


ABORTION  AND  PREMATURE  LABOR.  249 

tion  to  admit  of  its  passage.  This  is  gradually  effected  by  the  continu- 
ance of  pains,  but  not  without  a  severe  loss  of  blood.  It  may  be  that  the 
amnion  is  ruptured  and  the  foetus  expelled  first.  After  a  lapse  of  time 
the  secundines  are  also  shed,  but  there  may  be  a  considerable  delay, 
amounting  even  to  days,  before  this  is  effected.  As  long  as  any  por- 
tions of  the  membranes  are  retained  in  utero  the  patient  is  necessarily 
subjected  to  considerable  risk,  not  only  from  the  continuance  of  hemor- 
rhage, but  also  from  septicsemia.  Hence  it  may  be  laid  down  as  a  rule 
that  we  can  never  consider  our  patient  out  of  danger  until  we  have  sat- 
isfied ourselves  that  the  whole  of  the  uterine  contents  have  been  expelled. 

Trecdmmt. — Our  first  endeavor  in  any  case  of  impending  miscarriage  I 
will  be,  of  course,  to  avert  the  threatened  accident.    If  hemorrhage  has  not ' 
been  excessive,  and  if  on  vaginal  examination — which  should  always  be 
practised — we  find  no  dilatation  of  the  os,  we  may  entertain  a  reasonable 
hope  of  success.     If,  on  the  contrary,  we  find  the  os  beginning  to  open,  , 
if  we  are  able  to  insert  the  finger  through  it  so  as  to  touch  the  ovum,  i 
especially  if  pains  also  exist,  we  are  justified  in  considering  abortion  to  ) 
be  inevitable,  and  the  indication  will  then  be  to  have  the  ovum  expelled  I 
and  the  case  terminated  as  soon  as  possible.     In  the  former  case  thei    ex 
most  absolute  rest  is  the  first  thing  to  insist  on.     The  patient  should  be       ^ 
placed  in  bed,  not  overburdened  with  clothes,  in  a  cool  temperature,  and 
she  should  have  a  light  and  easily-assimilated  diet.     All  movements, 
even  rising  out  of  bed  to  empty  the  bladder  or  bowels,  should  be  abso- 
lutely prohibited.     To  avert  the  tendency  to  the  commencement  of  ute- 
rine contraction  there  is  no  remedy  so  useful  as  opium,  which  must  be      wp 
given  freely  and  frequently  repeated.     It  may  be  administered  either  in 
the  form  of  laudanum  or  of  Battley's  sedative  solution,  which  has  the 
advantage  of  producing  less  general  disturbance.    It  may  be  advantage- 
ously exhibited  in  doses  of  from  20  to  30  minims,  and  repeated  after  a 
few  hours.    A  still  betterjpreparation  is  chlorodyne,  which  I  have  found 
of  extreme  value  in  arresting  impending  miscarriage,  in  doses  of  10 
minims  repeated  every  third  or  fourth  hour.     If,  from  any  other  cause, 
it  is  considered  unadvisable  to  give  the  sedative  by  the  mouth,  it  may  be 
administered  in  a  small  starch  enema  per  rechmi.    In  all  cases  it  will  be 
necessary  to  keep  the  patient  more  or  less  under  the  influence  of  the  drug 
for  several  days  and  until  all  symptoms  of  miscarriage  have  passed 
away.    Care  should  be  taken  that  the  bowels  do  not  become  locked  up 
by  the  action  of  the  opiates — as  this  might  of  itself  be  a  cause  of  irrita- 
tion— and  their  constipating  effects  ought  to  be  obviated  by  small  doses 
of  castor  oil  or  other  gentle  aperient.     Various  subsidiary  methods  of 
treatment  have  been  recommended,  such  as  bleeding  from  the  arm  or  the 
local  application  of  leeches  in  supposed  plethoric  states  of  the  system ; 
revulsives,  such  as  dry  cup])ing  to  the  loins ;  the  application  of  ice,  to 
check  hemorrhage  ;  astringents,  such  as  acetate  of  lead  or  gallic  acid,  for 
the  same  purpose.     Most  of  these,  if  not  hurtful,  will  be  at  least  use- 
less.    The  cases  in  which  venesection  would  l)e  beneficial  are  extremely 
rare,  and  the  local  applications,  especially  c;old,  are  much  more  a]:)t  to 
favor  than  to  prevent  uterine  action. 

Propb^fj/M(iTrmtmmt — In  cases  of  repeated  miscarriage  in  successive 
pregnancies  a  special  course  of  prophylactic  treatment  is  indicated,  and 


250  PREGNANCY. 

is  often  attended  with  much  success.    In  cases  of  this  kind  the  first  indi- 

1  cation,  and  one  which  ought  to  be  carefully  attended  to,  is  to  seek  for 

j  and,  if  possible,  to  remove  or  mitigate  the  cause  which  has  given  rise  to 

\  the  former  abortions.      Those  causes  which   depend  on  constitutional 

states  must  first  be  carefully  investigated,  and  treated  according  to  the 

indications  present.     These  may  be  obscure  and  not  easily  discovered  ; 

but  it  is  certainly  unwise  to  assume  too  readily  the  existence  of  what 

has  been  called  "  a  habit  of  abortion/'  ^vhich  further  inquiiy  may  })rove 

to  be  only  an  indication  of  constitutional   debility,  degeneracy  of  the 

placental  structures,  or  a  latent  and  unsuspected  syphilitic  taint.     If 

constitutional  debility  be  present  to  a  marked  extent,  a  generous  diet  and 

a  restorative  course  of  treatment  (preparations  of  iron,  quinine,  and 

other  suitable  tonics)  may  eifect  the  desired  object. 

[As  an  evidence  of  the  efficiency  of  opium,  I  once  succeeded  in  arrest- 
ing a  labor  at  four  and  a  half  months  by  repeated  doses  of  sulphate  of 
morphia,  in  the  case  of  a  lady  who  was  in  a  decidedly  parturient  state 
for  ten  hours,  with  recurrent  uterine  contractions,  accompanied  by  pain 
and  a  considerable  loss  of  blood.  Under  the  narcotic  the  pains  became 
more  and  more  infrequent  until  they  finally  ceased,  and  the  patient  car- 
ried the  foetus  to  the  full  period.  It  was  a  small  female  child,  and  lived 
some  months,  its  delicacy  being  largely  due  to  the  fiict  that  its  mother 
was  phthisical.  In  another  case  labor  was  arrested  at  eight  months,  and 
the  foetus  was  carried  to  the  full  period.  In  the  hands  of  some  obstet- 
ricians the  fluid  extract  of  Yihurnum  prmiifolnon  would  appear  to  act 
efficiently  as  a  preventive  of  abortion  in  cases  where  the  habit  is  known 
to  exist.  In  one  case  of  this  habit,  after  repeated  failures,  a  residence 
in  a  mountainous  region  carried  the  patient  through  the  usual  period  of 
danger,  and  the  foetus  is  now  a  young  lady.  The  mother  was  of  very 
full  habit,  asthmatic,  and  at  times  rheumatic,  but  otherwise  in  excellent 
health.  She  usually  aborted  at  six  weeks.  After  three  months  she  had 
occasional  threatenings,  but  not  any  during  the  last  Uvo  months.  Rest 
in  bed  checked  any  apparent  tendency  to  miscarry. — Ed.] 

Treatment  in  Cases  depending  on  Local  Causes. — Local  congestion  of 
the  uterus  or  a  general  plethoric  state  of  the  patient  has  often  been  sup- 
posed to  be  an  efficient  cause  of  recurring  abortion.  Dr.  Henry  Bennet 
has  especially  dwelt  on  the  influence  of  congestion  and  abrasions  of  the 
cervix  in  causing  premature  expulsion  of  the  foetus,^  and  recommends 
the  topical  application  of  nitrate  of  silver  or  other  caustics  to  the  inflam- 
matory abrasions  existing  on  the  neck  of  the  womb.  Formerly  vene- 
section was  a  favorite  remedy  ;  and  many  authors  have  recommended 
the  local  abstraction  of  blood  by  leeches  applied  to  the  groin  or  round 
the  anus,  or  even  to  the  cervix.  The  influence  of  general  plethora  is 
more  than  doubtful ;  and  although  local  congestions  are,  probably,  nuich 
more  effective  causes,  still  it  would  seem  more  judicious  to  treat  them 
by  rest  and  local  sedatives  rather  than  by  topical  applications,  which, 
injudiciously  applied,  might  produce  the  very  accident  they  were  in- 
'.  tended  to  prevent. 

The  position  of  the  uterus  should  be  ,carefully  investigated.  If  it  be 
found  to  be  retroflexed,  a  well-fitting  Hodge's  pessary  should  be  ap- 

^  On  Inflammation  of  the  ZJi'erHS,  p.  432. 


ABORTION  AND  PREMATURE  LABOR.  251 

plied,   so  as  to  support  it  until   it  has    completely   risen   out  of  the 
pelvis. 

Treatment  in  Cases  depending  on  Syphilis. — The  possibility  of  syph- 
ilitic infection  should  always  be  inquired  into,  for  this  poison  may  act 
on  the  product  of  conception  long  after  all  appreciable  traces  of  it  have 
disappeared  from  the  infected  parent.  Should  there  be  recurrent  abor- 
tions in  a  patient  who  had  formerly  suffered  from  syphilis  or  whose 
husband  had  at  any  time  contracted  the  disease,  no  time  should  be  lost 
in  using  appropriate  antisyphilitic  remedies,  which  should  invariably  be 
administered  botli^to  the  husband  and  wife.  Diday  especially  insists 
that  in  such  cases  it  is  not  sufficient  to  submit  the  father  and  mother  to 
a  mercurial  course  in  the  absence  of  pregnancy,  but  that,  as  each  suc- 
cessive impregnation  occurs,  the  mother  should  again  commence  anti- 
syphilitic  treatment,  even  though  she  has  no  visible  traces  of  the  disease.^ 
In  this  way  there  is  reasonable  ground  for  hoping  that  infection  of  the 
ovum  may  be  prevented.  I  think,  too,  that  we  may  be  the  more 
encouragecl  to  persevere  in  the  treatment  of  these  unfortunate  cases 
from  the  fact  that  the  syphilitic  poison  tends  to  wear  itself  out.  I 
have  seen  several  cases  in  which  this  taint  at  first  produced  early  abor- 
tion, then  each  successive  pregnancy  was  of  longer  duration,  until 
eventually  a  living  child  was  born. 

In  fatty  degeneration  of  the  chorion  villi  and  in  other  morbid  states  of 
the  placenta,  which  act  by  preventing  the  proper  nutrition  of  the  foetus 
and  the  due  aeration  of  its  blood,  there  is  no  reliable  means  of  treat- 
ment except  the  general  improvement  of  the  mother's  health.  Simpson 
strongly  recommended  the  administration  of  chlorate  of  potash  in  cases 
in  which  the  child  habitually  dies  in  the  latter  months  of  pregnancy,  on 
the  supposition  that  it  supplied  to  the  blood  a  large  amount  of  oxygen, 
and  thus  made  up  for  any  deficiency  in  the  supply  of  that  element 
through  the  placental  tufts.  The  theory  is  at  best  a  doubtful  one, 
although  I  believe  the  drug  to  be  unquestionably  beneficial  in  cases  of 
the  kind.p]  It  probably  acts  by  its  tonic  properties  rather  than  in  the 
manner  Simpson  supposed.  It  may  be  given  in  doses  of  15  to  20 
grains  three  times  a  day,  and  may  be  advantageously  combined  with 
small  doses  of  dilute  hydrochloric  acid.  In  frequently-recurring  pre- 
mature labors  with  dead  children  Simpson  strongly  recommended  the 
induction  of  premature  labor  a  little  before  the  time  at  which  we  had  I 
reason  to  believe  that  the  foetus  has  usually  perished ;  or,  in  other  I 
words,  before  the  placental  disease  had  advanced  sufficiently  far  to ' 
interfere  with  its  nutrition.  The  practice  has  constantly  been  adopted 
with  success,  and  is  perfectly  legitimate,  but  the  difficulty,  of  course,  is 
to  fix  on  the  right  time.  Careful  auscultation  of  the  foetal  heart  may 
be  of  some  use  in  guiding  us  to  a  decision,  as  the  death  of  the  f(X3tus  is 
generally  preceded  for  some  days  by  irregular,  tumultuous,  and  intermit- 
tent action  of  the  heart. 

Treatment  vliere  no  Came  can  he  Discovered. — There  will  always 
remain  a  certain  number  of  cases  in  which  no  appreciable  cause  can  be 

'  Diday,  Tnfanfilc  Syphilid  Syd.  Soc.  TraiiH.,  p.  207. 

[^(Jlilorate  of  potiisli  will  nut,  j)art  with  its  ()xyf>en  except  at  a  red  heat.     In  the  sys- 
tem it  remains  unclianxcd,  as  proved  by  Prof.  Leeds  oi'  Iloboken. — P^i).] 


252 


PREGNANCY. 


discovered.  Under  such  circumstances  prolonged  rest,  at  least  until  the 
time  has  passed  at  which  abortion  formerly  took  place,  will  afford  the 
best  chance  of  avoiding  a  reciun^ence  of  the  accident.  There  must 
always  be  some  difficulty  in  carrying  out  this  indication,  inasmuch  as 
the  patient's  health  is  apt  to  suffer  in  other  ways  from  the  confinement 
and  the  want  of  fresh  air  and  exercise  which  it  entails.  The  strictness 
A\'ith  which  rest  should  be  insisted  on  must  vary  in  different  cases,  but 
it  should  be  specially  attended  to  at  what  would  have  been  the_  men- 
strual periods.  At  these  times  the  patient  should  remain  in  bed  alto- 
gether ;  at  others  she  may  lie  on  a  sofa,  and,  if  circumstances  permit, 
spend  pai't  of  the  day  at  least  in  the  open  air.  Sexual  intercourse 
should  be  prohibited.  Should  actual  symptoms  of  abortion  come  on, 
the  preventive  treatment,  already  indicated,  may  be  resorted  to.  Great 
care,  however,  should  be  used  in  prescribing  opiates  as  preventives,  and 
they  should  be  given  for  a  s];)ecified  time  only.  I  have  seen,  more  than 
once,  an  incurable  habit  of  opium-eating  originate  from  the  incautious 
and  too  long-continued  exhibition  of  the  drug  in  such  cases. 

When  we  have  satisfied  ourselves  that  abortion  is  inevitable,  we  must 
proceed  to  employ  treatment  that  favors  the  expulsion  of  the  ovum. 

Repioval  of  the  Ovum  when  within  Reach. — If  the  os  be  sufficiently 
dilated  and  the  pains  strong,  we  may  find  the  ovum  separated  and  pro- 
truding from  the  os.  We  may  then  be  able  to  detach  it  by  the  finger. 
For  this  purpose  the  uterus  is  depressed  from  without  by  the  left  hand, 
while  an  endeavor  is  made  to  scoop  out  the  ovum  with  the  examining 
finger.  If  it  be  out  of  reach,  and  yet  appears  detached,  chloroform 
should  be  administered,  the  whole  hand  introduced  into  the  vagina,  and 
the  finger  into  the  uterine  cavity.  The  complete  detachment  of  the 
ovum  can  in  this  way  be  far  more  readily  and  safely  effected  than  by 
using  any  of  the  many  ovum-forceps  which  have  been  invented  for  the 
purpose. 

Plugging  of  the  Vagina. — If  the  ovum  be  not  sufficiently  separated 
or  the  OS  be  undilated,  means  must  be  taken  to  control  the  hemorrhage 
until  the  former  can  be  removed  or  expelled.  It  is  here  that  plugging 
of  the  vagina  finds  its  most  useful  application.  This  may  be  done  in 
various  ways.  That  most  usually  employed  is  filling  the  vagina  with  a 
tolerably  large  sponge,  in  the  interstices  of  which  the  blood  coagulates. 
A  better  plan  is  to  soak  a  number  of  pledgets  of  cotton  wool  in  carbol- 
ized  water  and  tie  a  string  round  each.  The  vagina  can  be  completely 
and  effectively  packed  with  these,  and  this  is  best  done  through  a  specu- 
lum. Each  pledget  should  be  covered  with  glycerin,  which  completely 
prevents  the  offensive  odor  which  otherwise  always  arises.  The  pledgets 
can  be  removed  by  traction  on  the  strings,  but  if  these  are  not  used  much 
pain  is  caused  in  getting  them  out  of  the  vagina.  The  plug  should 
never  be  left  in  for  more  than  six  or  eight  hours,  after  which  a  fresh  one 
may  be  inserted  if  necessary.  Two  or  three  full  doses  of  the  liquid 
extract  of  ergot,  of  f^ss  to  foj  each,  or  a  subcutaneous  injection  of  ergo- 
tin,  may  be  given  while  the  plug  is  in  position.  The  plug  itself  is  a 
strong  excitant  of  uterine  action,  and  the  two  combined  often  effect  com- 
plete detachment,  so  that  on  the  removal  of  the  tampon  the  ovum  may 
be  found  lying  loose  in  the  os  uteri.     If  the  os  be  undilated  and  the 


ABORTION  AND  PREMATURE  LABOR.  253 

ovimi  entirely  out  of  reach,  the  former  may  be  opened  by  means  of  sponge 
or  laminaria  tents.  I  think  a  well-prepared  sponge  tent  the  most  effectual, 
and  it  can  be  maintained  in  situ  by  a  vaginal  plug  below  it.  It  also  acts 
as  a  most  efficient  plug,  effectually  controlling  all  hemorrhage.  In  a 
few  hours  it  opens  up  the  os  sufficiently  to  admit  the  finger. 

Retention  ojthe  Membranes. — The  most  troublesome  cases  are  those  in 
which  the  foetus  is  first  expelled  and  the  placenta  and  membranes  remain 
in  utero.  As  long  as  this  is  the  case  the  patient  can  never  be  con- 
sidered safe  from  the  occurrence  of  septicsemia.  Dr.  Priestley  has 
strongly  insisted  on  the  importance  of  removing  the  secundines  as  soon 
as  possible.  There  can  be  no  doubt  that  this  should  be  done  whenever 
it  is  feasible.  Cases,  however,  are  frequently  met  with  in  which  any 
forcible  attempt  at  removal  would  be  likely  to  prove  very  hurtful,  and 
in  which  it  is  better  practice  to  control  hemorrhage  by  the  plug  or  sponge 
tent,  and  wait  until  the  placenta  is  detached,  which  it  will  generally  be 
in  a  day  or  two  at  most.  Under  such  circumstances  fetor  and  decompo- 
sition of  the  secundines  may  be  prevented  by  intra-uterine  injections  of 
diluted  Condy's  fluid.  Provided  the  os  be  sufficiently  patulous  to  pre- 
vent the  collection  of  the  fluid  in  the  uterine  cavity,  and  not  more  than 
a  drachm  or  two  of  fluid  be  injected  at  a  time,  so  as  simply  to  wash 
away  and  disinfect  decomposing  detritus,  they  can  be  used  with  perfect 
safety.  Sometimes  cases  are  met  with  in  which  the  os  has  entirely  closed, 
and  in  which  we  can  only  suspect  the  retention  of  the  placenta  by  the 
history  of  the  case,  the  continuance  of  hemorrhage,  or  the  presence  of  a 
fetid  discharge.  Should  we  see  reason  to  suspect  this,  the  os  must  be 
dilated  ^vith  sponge  or  laminaria  tents  and  the  uterine  cavity  thoroughly 
explored  under  chloroform.  This  condition  of  things  is  far  from  uncom- 
mon in  women  Avho  have  not  had  medical  assistance  from  the  first,  and 
it  often  gives  rise  to  very  troublesome  and  anxious  symptoms.  It  has 
been  said  that  placentae  thus  retained  have  been  completely  absorbed, 
and  cases  of  the  kind  have  been  related  by  Naegele  and  Osiander.  The 
spontaneous  absorption,  however,  of  so  highly  organized  a  body  as  the 
placenta  would  be  a  phenomenon  of  the  most  remarkable  character  ;  and 
it  seems  more  natural  to  suppose  that  in  most  cases  of  the  kind  the  pla- 
centa has  been  cast  off  without  the  knowledge  of  the  patient.  Some- 
times the  placenta  never  entirely  becomes  detached,  and,  retaining  organic 
connection  with  the  uterine  walls,  forms  what  has  been  called  a  ^'placen- 
tol  polypus.''  This  may  produce  secondary  hemorrhages,  in  the  same 
way  as  an  ordinary  fibroid  polypus.  Barnes  recommends  the  removal 
of  these  masses  by  means  of  the  wire  ecraseur.  Before  their  detection 
the  OS  uteri  must  be  opened  up. 

Retention  in  Utero  of  a  BUyhted  Ovum. — The  cases  previously  alluded 
to,  in  which  an  ovum  has  perished  in  early  pregnancy  and  is  retained  in 
utero,  are  often  puzzling,  and  may  give  rise  to  serious  moral  and  medico- 
legal fjuestions.  The  blighted  ovum  may  be  retained  for  many  monlhs, 
the  outside  limit,  according  to  M(!(ylintock,^  by  whom  the  subject  has 
been  ably  discnssed,  l)ciiig  nine  months.  Tlic  apj)earancc  of  the  ovum 
when  thrown  off  will  give  no  reliable  clue  to  the  length  of  time  which 
has  elapsed  since  it  perished.     The  symptoms  are  often  very  obscure. 

'  SyclenlKini'H  Society's  c<l.  of  SmeUlc's  Mi/lwifci/,  vol.  i.  p.  ]()9. 


254  PREGNANCY. 

Generally  there  have  been  the  n.sual  indications  of  pregnancy,  which,  with 
or  without  signs  of  impending  miscarriage,  disappear  or  are  modified,  and 
then  follows  a  ])eriod  of  ill-health,  with  pelvic  uneasiness  and  irregular 
metrorrhagia,  which  may  be  mistaken  for  menstruation.  Occasionally, 
but  by  no  means  necessarily,  there  is  a  fetid  discharge,  and  this  probably 
exists  only  when  the  membranes  have  broken  and  air  has  access  to  the 
ovum.  In  some  cases  obscure  septicsemic  symptoms  have  been  observed. 
Such  symptoms  are  obviously  too  indefinite  to  lead  to  an  accurate  diag- 
nosis. In  the  course  of  time  the  ovum  is  generally  thrown  off,  with 
more  or  less  hemorrhage.  If  the  nature  of  the  case  is  detected,  ergot 
may  be  given  to  promote  the  expulsion  of  the  uterine  contents,  and  it 
may  even  be  advisable  to  dilate  the  cervix  with  sponge  or  laminaria 
1  tents  and  remove  them  artificially. 

Subsequent  Ilcmagement. — The  frequency  with  which  abortion  leads 
to  chronic  uterine  disease  should  lead  us  to  attach  much  more  importance 
to  the  subsequent  management  of  the  patient  than  has  been  customary. 
The  usual  practice  is  to  confine  the  patient  to  bed  for  two  or  three  days 
only,  and  then  to  allow  her  to  resume  her  ordinary  avocations,  on  the 
supposition  that  a  miscarriage  requires  less  subsequent  care  than  a  con- 
finement. The  contrary  of  this  is,  however,  most  probably  the  case,  for 
the  uterus  has  been  emptied  when  it  is  unprepared  for  involution,  and 
that  process  is  often  very  imperfectly  performed.  We  should  therefore 
insist  on  at  least  as  much  attention  being  paid  to  rest  as  after  labor  at 
term.  [A  common  cause  of  uterine  hypeiylasia  is  the  imperfect  invo- 
lution which  is  apt  to  follow  an  abortion  at  an  early  period  of  gestation, 
especially  when  the  patient  is  not  properly  treated  by  rest  in  a  recumbent 
position.  Displacements  of  the  uterus  are  apt  to  be  produced  by  the 
erect  position  and  exercise  while  the  organ  is  heavy  and  its  ligaments 
relaxed. — Ed.] 


PART  Til 

LABOR. 


CHAPTER   I. 

THE  PHENOMENA  OF  LABOR. 

Delivery  at  Term. — In  considering  delivery  at  term  we  have  to  discuss 
two  distinct  classes  of  events. 

One  of  these  is  the  series  of  vital  actions  brought  into  play  in  order  to 
eifect  the  expulsion  of  the  child ;  and  the  other  consists  of  the  move- 
ments imparted  to  the  child,  the  body  to  be  expelled — in  other  words, 
the  mechanism  of  delivery. 

Causes  of  Labor. — Before  proceeding  to  the  consideration  of  these 
important  topics  a  few  words  may  be  said  as  to  the  determining  causes 
of  labor.  This  subject  has  been  from  the  earliest  times  a  qucestio  vexata 
among  physiologists,  and  many  and  various  are  the  theories  which  have 
been  broached  to  explain  the  curious  fact  that  labor  spontaneously  com- 
mences, if  not  at  a  fixed  epoch,  at  any  rate  approximately  so.  It  must 
be  admitted  that  even  yet  there  is  no  explanation  which  can  be  implicitly 
accepted. 

Foetal  or  Maternal  Causes. — The  explanations  which  have  been  given 
may  be  divided  into  two  classes — those  which  attribute  the  advent  of  labor 
to  the  foetus,  and  those  which  refer  it  to  some  change  connected  with  the 
maternal  generative  organs. 

The  former  is  the  o])inion  which  was  held  by  the  older  accoucheurs, 
who  assigned  to  the  foetus  some  active  influence  in  effecting  its  own 
expulsion.  It  need  hardly  be  said  that  such  fanciful  views  have  no 
kind  of  ])hysiological  basis.  Others  have  supposed  that  there  might  be 
some  change  in  the  placental  circulation  or  in  the  vascular  system  of  the 
f(etus  which  might  solve  the  mystery.  The  latest  hypothesis  of  this 
kind — which,  however,  is  not  fortified  by  any  evidence — is  by  Barnes, 
who  says :  "  I  rather  incline  to  the  opinion  that  when  the  foetus  has 
attained  its  full  develo])ment,  when  its  organs  are  prepared  for  external 
life,  some  change  takes  place;  in  its  circulation  which  involves  a  correla- 
tive disturbance  in  the  maternal  circulation,  which  excites  the  attempt  at 
labor."' 

The  majority  of  obstetri("ians,  however,  refer  the  advent  of  hibor  to 
purely  maternal  causes.    Among  the  more  favorite  theories  is  one  which 

'  DiHeamH  of  Women,  \).  A?>A. 

255 


256  LABOR. 

was  originally  started  in  this  country  by  Dr.  Power  and  adopted  and 
illustrated  by  Depaul,  Dubois,  and  other  writers.  It  is  based  on  the 
assumption  that  there  is  a  sphincter  action  of  the  fibres  of"  the  cervix 
analogous  to  that  of  the  sphincters  of  the  bladder  and  rectum,  and  that 
when  the  cervix  is  taken  up  into  the  general  uterine  cavity  as  pregnancy 
advances,  the  ovum  presses  upon  it,  irritates  its  nerves,  and  so  sets  up 
reflex  action,  which  ends  in  the  establishment  of  uterine  contraction. 
This  theory  was  founded  on  erroneous  conceptions  of  the  changes  that 
occurred  in  the  neck  of  the  uterus  ;  and,  as  it  is  certain  that  obliteration 
of  the  cervix  does  not  really  take  place  in  the  manner  that  Power 
believed  M'hen  his  theory  was  broached,  it  is  obvious  that  its  suj)posed 
result  cannot  follow. 

Distension  of  the  Uterus. — Extreme  distension  of  the  uterus  has  been 
held  to  be  the  determining  cause  of  labor — a  view  lately  revived  by  Dr. 
King  of  Washington,^  who  believes  that  contractions  are  induced 
because  the  uterus  ceases  to  augment  in  capacity,  while  its  contents  still 
continue  to  increase.  This  hypothesis  is  sufficiently  disproved  by  a 
number  of  clinical  facts  which  show  that  the  uterus  may  be  subject  to 
excessive  and  even  rapid  distension — as  in  cases  of  hydramnios,  multiple 
pregnancy,  and  hydatidiform  degeneration  of  the  ovum — without  the 
supervention  of  uterine  contractions. 

Fatty  Degeneration  of  the  Decidua. — Another  inciter  of  uterine  action 
has  been  supposed  to  be  the  separation  of  the  ovum  from  its  connections 
to  the  uterine  parietes  in  consequence  of  fatty  degeneration  of  the  decidua 
occurring  at  the  end  of  pregnancy.  The  supposed  result  of  this  change, 
which  undoubtedly  occurs,  is  that  the  ovum  becomes  so  detached  from 
its  organic  adhesions  as  to  be  somewhat  in  the  position  of  a  foreign  body, 
and  thus  incites  the  nerves  so  largely  distributed  over  the  interior  of  the 
uterus.  This  theory,  which  has  been  widely  accepted,  was  originally 
started  by  Sir  James  Simpson,  who  pointed  out  that  some  of  the  most 
efficient  means  of  inducing  labor  (such,  for  example,  as  the  insertion  of 
a  gum-elastic  catheter  between  the  ovum  and  the  uterine  walls)  probably 
act  in  the  same  way — viz.  by  effective  separation  of  the  membranes  and 
detachment  of  the  ovum. 

Barnes  instances,  in  opposition  to  this  idea,  the  fact  that  ineffectual 
attempts  at  labor  come  on  at  the  natural  term  of  gestation  in  cases  of 
extra-uterine  pregnancy,  when  the  foetus  is  altogether  independent  of 
the  uterus,  and  therefore,  he  argues,  the  cause  cannot  be  situated  in  the 
uterus  itself.  A  fair  answer  to  this  argument  would  be  that  although, 
in  such  cases,  the  womb  does  not  contain  the  ovum,  it  does  contain  a 
decidua,  the  degeneration  and  separation  of  which  might  suffice  to 
induce  the  abortive  and  partial  attempts  at  labor  then  witnessed. 

Objections  to  these  Theories. — A  serious  objection  to  all  these  theories, 
which  are  based  on  the  assumption  that  some  local  irritation  brings  on 
contraction,  is  the  fact,  which  has  not  been  generally  appreciated,  that 
uterine  contractions  are  always  present  during  pregnancy  as  a  normal 
occurrence,  and  that  they  may  be,  and  often  are,  readily  intensified  at 
any  time,  so  as  to  lesult  in  premature  delivery. 

It  is,  indeed,  most  likely  that,  at  or  about  the  full  term,  the  nervous 

^  American  Jour  mil  of  Obstetrics,  vol.  iii 


THE  PHENOMENA    OF  LABOR.  257 

supply  of  the  uterus  is  so  highly  developed,  and  in  so  advanced  a  state 
of  irritability,  that  it  more  readily  responds  to  stimuli  than  at  other 
times.  If  by  separation  of  the  decidua,  or  in  some  other  way,  stimula- 
tion of  the  excitor  nerves  is  then  effected,  more  frequent  and  forcible 
contractions  than  usual  may  result,  and,  as  they  become  stronger  and 
more  regular,  terminate  in  labor.  But,  allowing  this,  it  still  remains 
quite  unexplained  why  this  should  occur  with  such  regularity  at  a  def- 
inite time. 

Tyler  Smith's  Ovarian  Theory. — Tyler  Smith  tried,  indeed,  to  prove 
that  labor  came  on  naturally  at  what  would  have  been  a  menstrual 
epoch,  the  congestion  attending  the  menstrual  nisus  acting  as  the  exciter 
of  uterine  contraction.  He  therefore  refers  the  onset  of  labor  to  p.varianl  '  ". 
rather  than  to  uterine  causes.  Although  this  view  is  upheld  with  all  it§,'  '^"j^^ 
author's  great  talent,  there  are  several  objections  to  it  difficult  to  over- 
come. Thus,  it  assumes  that  the  periodic  changes  in  the  ovary  continue 
during  pregnancy,  of  which  there  is  no  proof.  Indeed,  there  is  good  rea- 
son to  believe  that  ovulation  is  suspended  during  gestation,  and  with  it, 
of  course,  the  menstrual  iiftsus.  Besides,  as  has  been  well  objected  by 
Cazeaux,  even  if  this  theoiy  were  admitted,  it  would  still  leave  the  mys- 
tery unsolved,  for  it  would  not  explain  why  the  menstrual  nisus  should 
act  in  this  way  at  the  tenth  menstrual  epoch  rather  than  at  the  ninth  or 
eleventh. 

In  spite,  then,  of  many  theories  at  our  disposal,  it  is  to  be  feared  that 
we  must  admit  ourselves  to  be  smll  in  .entire.igJiQraiice  of  the  reason 
why  labor  should  come  on  at  a  fixed  epoch. 

Mode  in  lohich  the  Expulsion  of  the  Child  is  Ejected. — The  expulsion 
of  the  child  is  effected  by  the  contractions  of  the  muscular  fibres  of  the 
uterus,  aided  by  those  of  some  of  the  abdominal  muscles.  These  efforts 
are  in  the  main  entirely  independent  of  volition.  So  far  as  regards  the 
uterine  contractions,  this  is  absolutely  true,  for  the  mother  has  no  power 
of  originating,  lessening,  or  increasing  the  action  of  the  uterus.  As 
regards  the  abdominal  muscles,  however,  the  mother  is  certainly  able  to 
bring  them  into  action  and  to  increase  their  power  by  voluntary  efforts ; 
but,  as  labor  advances  and  as  the  head  passes  into  the  vagina  and  irri- 
tates the  nerves  supplying  it,  the  abdominal  muscles  are  often  stimulated 
to  contract,  through  the  influence  of  reflex  action,  independently  of  voli- 
tion on  the  part  of  the  mother. 

The  Chief  Factor  in  Expulsion. — There  can  be  little  doubt  that  the 
chief  agent  in  the  expulsion  of  the  child  is  the  contraction  of  the  uterus 
itself  Tliis  opinion  is  almost  unanimously  held  by  accoucheurs,  and 
the  influence  of  the  abdominal  muscles  is  believed  to  be  purely  accessory. 
Dr.  Haughton,  however,  maintains  a  view  which  is  directly  contrary  to 
this.  From  an  examination  of  the  force  of  the  uterine  contractions, 
arrived  at  by  measvnnng  the  amount  of  muscular  fibre  contained  in  the 
\Vd\U  of  the  uterus,  he  arrives  at  the  conclusion  tliat  the  uterine  contrac- 
tions are  (;hiclly  influential  in  rupturing  the  membranes  and  dilating  the 
OS  uteri,  l)ringing  into  action,  if  needful,  a  force  equivalent  to  54  lbs. ; 
but  when  tliis  is  effected,  and  the  second  stage  of  labor  has  commenced, 
he  thinks  the  remainder  of  the  labor  is  mainly  completed  by  the  contrac- 
tions of  tlie  abdominal  nuiscles,  to  which  he  attributes  enormous  powers 
17 


258  LABOR. 

— equivalent,  if  needful,  to  a  pressure  of  523.65  lbs.  on  the  area  of  the 
pelvic  canal. 

These  views  bear  on  a  topic  of  primary  consequence  in  the  physiology 
of  labor.  They  have  been  fully  criticised  by  Duncan,  who  has  devoted 
much  experimental  research  to  the  study  of  the  powers  brought  into 
action  in  the  expulsion  of  the  child.  His  conclusions  are  that,  so  far 
from  the  enormous  force  being  employed  that  Haughton  estimated,  in 
the  large  majority  of  cases  the  effective  force  brought  to  bear  on  the 
child  by  the  combined  action  of  both  the  uterine  and  abdominal  muscles 
is  less  than  50  lbs.  ;  that  is,  less  than  the  force  which  Haughton  attrib- 
uted to  the  uterus  alone.  In  extremely  severe  labors,  when  the  resist- 
ance is  excessive,  he  thinks  that  extra  power  may  be  employed,  but  he 
estimates  the  maximum  as  not  above  80  lbs.,  including  in  this  total  the 
action  of  both  the  uterine  and  abdominal  muscles.  Joulin  arrived  at  the 
conclusion  that  the  uterine  contractions  were  capable  of  resisting  a  max- 
imum force  of  about  one  hundredweight.  Both  these  estimates,  it  will 
be  observed,  are  much  under  that  of  Haughton,  which  Duncan  describes 
as  rej^resenting  "  a  strain  to  which  the  maternal  machinery  could  not  be 
subjected  without  instantaneous  and  utter  destruction." 

Reasons  on  which  this  Conclusion  is  Based. — There  are  many  facts  in 
the  history  of  parturition  which  make  it  certain  that  the  chief  factor  in 
the  expulsion  of  the  child  is  the  uterus.  Among  these  may  be  men- 
tioned occasiolial  cases  in  which  the  action  of  the  abdominal  muscles  is 
materially  lessened,  if  not  annulled — as  in  profound  anaesthesia  and  in 
some  cases  of  paraplegia — in  which,  nevertheless,  uterine  contractions 
suffice  to  effect  delivery.  The  most  familiar  example  of  its  influence, 
however,  and  one  that  is  a  matter  of  every-day  observation  in  practice, 
is  when  inertia  of  the  uterus  exists.  In  such  cases  no  effort  on  the  part 
of  the  mother,  no  amount  of  voluntary  action  that  she  can  bring  to  bear 
on  the  child,  has  any  appreciable  influence  on  the  progress  of  the  labor, 
which  remains  in  abeyance  until  the  defective  uterine  action  is  re-estab- 
lished or  until  artificial  aid  is  given. 

The  contraction  of  the  uterus,  then,  being  the  main  agent  in  delivery, 
it  is  important  for  us  to  appreciate  its  mode  of  action  and  its  effect  on 
the  ovum. 

Uterine  Contractions  at  the  Commencement  of  Labor. — AVe  have  seen 
that  intermittent  and  generally  painless  uterine  contractions  exist  during 
pregnancy.  As  the  period  for  delivery  approaches  these  become  more 
frequent  and  intense,  until  labor  actually  commences,  when  they  begin 
to  be  sufficiently  developed  to  effect  the  opening  up  of  the  os  uteri  with 
a  view  to  the  passage  of  the  child.  They  are  now  accompanied  by  pain, 
which  increases  as  labor  advances,  and  is  so  characteristic  that  ''  pains  " 
are  universally  used  as  a  descriptive  term  for  the  contractions  themselves. 
It  does  not  necessarily  follow  that  uterine  contractions  are  painless  until 
they  commence  to  effect  dilatation  of  the  os  uteri.  On  the  contrary, 
during  the  last  days  or  even  weeks  of  pregnancy  women  constantly  have 
irregular  contractions,  accompanied  by  severe  suffering,  which,  however, 
pass  off  without  producing  any  marked  effect  on  the  cervix.  AMien 
labor  has  actually  begun,  if  the  hand  is  placed  on  the  uterus  when  a 
pain  commences  the  contraction  of  its  muscular  tissue  is  very  apparent. 


THE  PHENOMENA   OF  LABOR.  259 

and  the  whole  organ  is  observed  to  become  tense  and  hard,  the  rigidity 
increasing  until  the  pain  has  reached  its  acme,  the  uterine  walls  then 
relaxing  and  remaining  sofc  until  the  next  pain  comes  on.  At  the  com- 
mencement of  labor  these  pains  are  few,  separated  from  each  other  ])y  a 
considerable  interval,  and  of  short  duration.  In  a  perfectly  typical 
labor  the  interval  between  the  pains  becomes  shorter  and  shorter,  while, 
at  the  same  time,  the  duration  of  each  pain  is  increased.  At  first  they 
may  occur  only  once  in  an  hour  or  more,  while  eventually  there  may  not 
be  more  than  a  few  minutes'  interval  between  them. 

Mode  in  which  Dilatation  of  the  Cervix  is  Effected. — If,  when  the  pains 
are  fairly  established,  a  vaginal  examination  be  made,  the  os  uteri  will 
be  found  to  be  thinned  and  dilated  in  proportion  to  the  progress  of  the 
labor.  During  the  contraction  the  bag  of  membranes  will  be  felt  to 
bulge,  to  become  tense  from  the  downward  pressure  of  the  liquor  amnii 
within  it,  and  to  protrude  through  the  os  if  it  be  sufficiently  open.  The 
membranes,  with  the  contained  liquor  amnii,  thus  form  a  fluid  wedge, 
which  has  a  most  important  influence  in  dilating  the  os  uteri  (see  Front- 
ispiece). This  does  not,  however,  form  the  sole  mechanism  by  which 
the  OS  uteri  is  dilated,  for  it  is  also  acted  upon  by  the  contractions  of 
the  muscular  fibres  of  the  uterus,  which  tend  to  pull  it  open.  It  is 
probable  that  the  muscular  dilatation  of  the  os  is  effected  chiefly  by  the 
longitudinal  fibres,  which,  as  they  shorten,  act  upon  the  os  uteri,  the 
part  "where  there  is  least  resistance. 

Partly,  then,  by  muscular  contraction,  partly  by  mechanical  pressure, 
the  cervical  canal  is  dilated,  and  as  it  opens  up  it  becomes  thinner  and 
thinner,  until  it  is  entirely  taken  up  into  the  uterine  cavity. 

Rupture  of  the  Membranes. — There  is  no  longer  any  obstacle  to  the 
passage  of  the  presenting  part  of  the  child  into  the  cavity  of  "the  pelvis, 
and  the  force  of  the  pains  now  generally  effects  the  rupture  of  the  mem- 
branes and  the  esca|)e  of  the  liquor  amnii.  Therels  often  observed,  at 
this  time,  a  temporary  relaxation  in  the  frequency  of  the  pains,  which 
had  been  steadily  increasing  ;  but  they  soon  recommence  with  increased 
vigor.  If  the  abdomen  be  now  examined,  it  will  be  observed  to  be 
much  diminished  in  size,  partly  in  consequence  of  the  escape  of  the 
liquor  amnii,  partly  from  the  descent  of  the  foetus  into  the  pelvic  cavity. 

Change  in  the  Character  of  the  Pains. — The  character  of  the  pains 
soon  changes.  They  become  stronger,  longer  in  duration,  separated  by  a 
shorter  interval,  and  accompanied  by  a  distinct  forcing  effort,  being  gen- 
erally described  as  ''the  bearing-down"  pains.  Now  is  the  time  at 
which  the  accessory  muscles  of  parturition  come  into  operation.  The 
patient  brings  them  into  play  in  the  manner  which  will  be  subsequently 
described,  and  the  combined  action  of  the  uterine  and  abdominal  mus- 
cles continues  until  the  expulsion  of  the  child  is  effected. 

Mode  of  Action  of  the  Uterus. — The  precise  mode  of  uterine  contrac- 
tion is  still  somewhat  a  matter  of  dis])ute.  It  is  generally  described  as 
commencing  in  the  cervix,  passing  gradually  u]>ward  by  peristaltic 
action,  the  wave  then  retui-ning  downward  toward  the  os  uteri.  This 
view  was  maintained  by  Wigand,  and  has  been  endorsed  by  lligby, 
Tyler  Smitli,  and  many  other  writers.  In  support  of  it  they  instance 
tlie  fiict  that  on  the  accession  of  a  pain  the  presenting  part  first  recedes; 


260  LABOR.       . 

the  bag  of  membranes  then  becomes  tense  and  protrudes  through  the  os, 
and  it  is  not  until  some  time  that  the  presenting  part  of  the  child  itself 
is  pushed  down.  It  is  very  doubtful  if  this  view  is  correct ;  and  a  care- 
ful examination  of  the  course  of  the  pains  would  rather  lead  to  the 
belief  that  the  contractions  commence  at  the  fundus,  where  the  muscular 
tissue  is  most  largely  developed,  and  gradually  proceed  downward  to  the 
cervix,  the  waves  of  contraction  being,  however,  so  rapid  that  the  whole 
organ  seems  to  harden  en  masse.  The  apparent  recession  of  the  present- 
ing part  and  the  bulging  of  the  bag  of  membranes  are  certainly  no  proof 
that  the  contractions  begin  at  the  cervix  ;  for  the  commencing  contraction 
would  necessarily  push  down  the  fluid  in  front  of  the  head,  and  cause 
the  membranes  to  bulge  and  the  os  to  become  tense  before  its  force  was 
brought  to  bear  on  the  foetus  itself.  Indeed,  did  the  contraction  com- 
mence at  the  lower  part  of  the  uterus,  we  should  expect  the  opposite  of 
what  takes  place  to  occur,  and  the  waters  to  be  pushed  upward  and 
away  from  the  cervix.  The  fundal  origin  of  the  contraction  is  further 
illub^trated  by  what  is  observed  when  the  hand  of  the  accoucheur  is 
placed  in  the  uterine  cavity,  as  often  happens  in  certain  cases  of  hem- 
orrhage or  turning ;  for  if  a  pain  then  comes  on,  it  will  be  felt  to 
start  at  the  fundus,  and  gradually  compress  the  hand  from  above 
downward. 

Value  of  the  Intermittent  Character  of  the  Pains. — The  intermittent 
character  of  the  contractions  is  of  great  practical  importance.  Were 
they  continuous,  not  only  would  the  muscular  powers  of  the  patient  be 
rapidly  exhausted,  but  by  the  obliteration  of  the  vessels  produced  by  the 
muscular  contraction  the  circulation  through  the  placenta  would  be  inter- 
fered with  and  the  life  of  the  child  imperilled.  Hence,  one  of  the  chief 
dangers  of  jDrotracted  labor,  especially  after  the  escape  of  the  liquor 
amnii,  is  that  the  uterine  fibres  may  enter  into  a  state  of  tonic  rigidity 
— a  condition  that  cannot  be  long  continued  without  serious  risks  both 
to  the  mother  and  child. 
\  The  Contractions  are  Incited  through  the  Sympathetic  Nerves. — The 
I  fact  that  the  uterine  contractions  are  altogether  involuntary  proves  them 
to  be  excited — as  indeed  we  would  a  priori  infer  from  our  knowledge 
of  the  anatomical  arrangement  of  the  nerves  of  the  uterus — solely  by 
the  sympathetic  system.  Still,  it  is  a  fact  of  every-day  observation  that 
they  can  be  largely  influenced  by  emotions.  Various  stimuli  applied  to 
the  spinal  system  of  nerves  (as,  for  example,  when  the  mammae  are  irri- 
tated) have  also  a  marked  effect  in  inducing  uterine  contraction.  The 
precise  mode  in  which  such  influence  is  conveyed  to  the  uterus,  in  spite 
of  the  numerous  experiments  which  have  been  made  for  the  purpose  of 
determining  how  far  labor  is  affected  by  destruction  of  the  spinal  cord, 
is  still  a  matter  of  doubt.  After  the  foetus  has  passed  through  the  cer- 
vix the  spinal  nerves  distributed  to  the  vagina  and  perineum  are  excited 
by  the  pressure  of  the  presenting  part,  and  through  them  the  accessory 
^powers  of  parturition  are  chiefly  brought  into  play.  The  contraction  of 
the  muscles  of  the  vagina  itself  is  supposed  to  have  some  influence  in  fav- 
oring the  expulsion  of  the  foetus  after  the  birth  of  part  of  the  body,  and 
also  in  promoting  the  expulsion  of  the  placenta.  In  the  lower  animals  the 
vagina  has  a  very  marked  contractile  property,  and  is,  in  some  of  them. 


THE  PHENOMENA   OF  LABOR.  261 

the  main  agent  by  which  the  young  are  expelled.    In  the  human  subject 
this  influence  is  certainly  of  very  secondary  importance. 

Character  and  Source  of  Pains  during  Labor. — The  amount  of  suf- 
fering experienced  during  labor  varies  much  in  different  cases,  and  is  in 
direct  proportion  to  the  nervous  susceptibility  of  the  patient.  There  are 
some  women  who  go  through  labor  with  little  or  no  pain  at  all.  This 
is  proved  by  the  cases  (of  which  there  are  numerous  authentic  instances 
recorded)  in  which  labor  has  commenced  during  sleep,  and  the  child  has 
been  actually  born  without  the  mother  awaking.  I  am  acquainted  with 
a  lady  who  has  had  a  large  family,  who  assures  me  that,  though  labor 
is  accompanied  by  a  sense  of  pressure  and  discomfort,  she  experiences 
nothing  which  can  be  called  actual  pain.  Such  a  happy  state  of  affairs 
is,  however,  extremely  exceptional,  and  in  the  vast  majority  of  cases  par- 
turition is  accompanied  by  intense  suffering  during  its  whole  course,  in 
some  cases  amounting  to  anguish  which  has  probably  no  parallel  under 
any  other  condition. 

The  precise  cause  of  the  pain  has  been  much  discussed,  and  is  no 
cldubt  complex. 

InJhx^First^Btage. — In  the  early  stage  of  labor,  and  before  the  dilata- 
tion of  the  OS,  it  is  chiefly  seated  in  the  back,  from  Avhence  it  shoots 
round  the  loins  and  down  the  thighs.  It  is  then  probably  produced ' 
partly  by  pressure  on  the  nerve-filaments,  caused  by  contraction  of  the 
muscular  fibres  to  which  they  are  distributed,  and  partly  by  stretching 
and  dilatation  of  the  muscular  tissue  of  the  cervix.  M.  Beau  believes 
that  in  this  stage  the  pain  is  not  produced,  strictly  speaking,  in  the  ute- 
rus itself,  but  is  rather  a  neuralgia  of  the  lumbo-abdominal  nerves.  The 
pains  at  this  time  are  generally  described  as  "acute"  and  "grinding" 
— ^terms  which  sufficiently  well  express  their  nature.  In  highly-nervous 
women  these  pains  are  often  much  less  well  borne  than  those  of  a  later 
stage,  and  the -suffering  they  undergo  is  indicated  by  their  extreme  rest- 
lessness and  loud  cries  as  each  contraction  supervenes.  As  the  os  dilates 
and  the  labor  advances  into  the  expulsive  stage  other  sources  of  suffer- 
ing are  added. 

In  the  Second  Stage. — The  presenting  part  now  passes  into  the  vagina 
and  presses  on  the  vaginal  nerves,  as  ^vell  as  on  the  large  nervous  plex- 
uses lying  in  the  pelvis.  As  it  descends  lower  it  stretches  the  perineum 
and  vulva  and  presses  on  the  bladder  and  rectum.  Hence  cramps  are 
prodiiced  hi^  the  muscles  supplied  by  the  nerve-plexuses,  aswell  as  an 
intoleralile  sense  of  tearing  and  stretching  in  the  vulva  and  perineum, 
and  often  a  distressing  feeling  of  tenesmus  in  the  bowels.  By  this  time 
the  accessory  muscles  of  parturition  are  brought  into  action,  and  they, 
as  well  as  the  uterine  muscles,  are  thrown  into  frequent  and  violent  con- 
tractions, which,  independently  of  the  other  causes  mentioned,  arc  sufii- 
ciont  of  themselves  to  ])roduce  great  pain,  likened  to  that  of  colic  pro- 
duced by  involuntary  and  repeated  contraction  of  the  muscles  of  tlie 
intestines. 

Taking  all  these  cruises  into  consideration,  there  is  no  lack  of  suffi- 
cient explanation  of  the  intolerable  suffering  which  is  so  constant  an 
accompaniment  of  childbirth. 

J'Jff'ect  of  the  Fains  on  the  Ifother  and  Foetus. — The  effect  of  the  pains 


262  LABOR. 

on  tlie  mother's  circulation  is  well  marked.  The  rapidity  of  the  pulse 
increases  distinctly  with  each  contraction,  and  as  the  pain  passes  oif  it  again 
declines  to  its  former  state.  A  similar  observation  has  been  made  with 
regard  to  the  sounds  of  the  foetal  heart,  especially  after  the  expulsion  of 
the  liquor  amnii.  Hicks  has  pointed  out  that  during  a  pain  the  nuis- 
cular  vibrations  give  rise  to  a  sound  which  often  resembles  that  of  the 
tcTetal  heart,  and  which  completely  disappears  when  the  muscular  tissue 
relaxes.  The  effect  of  the  pain  in  intensifying  the  uterine  souffle  has 
been  already  mentioned.  The  strong  muscular  efforts  would  naturally 
lead  us  to  expect  a  marked  elevation  of  temperature  during  labor.  Fur- 
ther observations  on  this  point  are  required,  but  Squire  asserts  that  there 
is  generally  <^nly  a  very  slight  increase  in  temperature  during  delivery, 
rapidly  passing  off  as  soon  as  labor  is  over. 

Division  of  Labor  into  Stages. — Such  being  the  physiological  facts  in 
connection  with  the  labor-pains,  we  may  now  describe  the  ordinary  prog- 
ress of  a  natural  labor — that  is,  one  terminated  by  the  natural  powers 
and  with  a  head  presenting. 

For  facility  of  description  obstetricians  have  long  been  in  the  habit 
of  dividing  the  course  of  labor  into  stages,  which  correspond  pretty 
.  accurately  with  the  natural  sequence  of  events.     For  this  purpose  we 
generally  talk  of  three  stages — viz. :  1,  from  the  commencement  of  regu- 
lar pains  until  the  complete  dilatation  of  the  cervix ;  2,  from  the  com- 
I  plete  dilatation  of  the  cervix  until  the  expulsion  of  the  child ;  3,  the 
concluding  stage,  comprising  the  permanent   contraction  of  the  uterus 
1  and  the  separation  and  expulsion  of  the  placenta.    To  these  we  may  con- 
/  veniently  add  a  preparatory  stage,  antecedent  to  the  regular  commence- 
ment of  the  labor. 

Preparatory  Stage. — For  a  short  time  before  delivery,  varying  from 
a  few  days  to  a  week  or  two,  certain  premonitory  symptoms  generally 
exist  which  indicate  the  approaching  advent  of  labor.  Sometimes  they 
j  I  are  well  marked,  and  cannot  be  mistaken  ;  at  others  they  are  so  slight 
I  as  to  escape  observation.  Amongst  the  most  common  is  a  sinking  of 
' '  the  uterus  into  the  pelvic  cavity,  resulting  from  the  relaxation  of  the 
soft  parts  preceding  delivery.  The  result  is,  that  the  upper  edge  of  the 
uterine  tumor  is  less  high  than  before,  and,  in  consequence,  the  pressure 
on  the  respiratory  organs  is  diminished,  and  the  woman  often  feels  lighter, 
and  altogether  less  unwieldy,  than  in  the  previous  weeks.  If  a  vaginal 
examination  be  made  at  this  time,  the  lower  segment  of  the  uterus  will 
be  found  to  have  sunk  lower  into  the  pelvic  cavity  ;  and  the  consequence 
of  this  is  that,  while  the  respiration  is  less  embarrassed  and  the  patient 
'  feels  less  bulky,  other  accompaniments  of  pregnancy,  such  as  hemor- 
rhoids, irritability  of  the  bladder  and  bowels,  and  oedema  of  the  limbs, 
become  aggravated.  The  increased  pressure  on  the  bowels  often  induces 
a  sort  of  temporary  diarrhoea,  which  is  so  far  advantageous  that  it  emp- 
ties the  bowels  of  feces  which  may  have  collected  within  them.  As  has 
already  been  pointed  out,  the  contractions  which  have  been  going  on  at 
intervals  during  the  latter  months  of  pregnancy  now  get  more  and  more 
marked,  and  they  have  the  effect  of  producing  a  real  shortening  of  the 
cervix,  which  is  of  great  value  preparatory  to  its  dilatation.  INIore 
marked  mucous  discharge  from  the  cavity  of  the  cervix  also  generally 


THE  PHENOMENA   OF  LABOR.  263 

occurs  a  short  time  before  labor,  and  it  is  not  unfreqaently  tinged  with  1 
blood  from  the  laceration  of  minute  capillary  vessels.  This  discharge,  1 
popularly  known  as  the  "  shoivs,"  is  a  pretty  sure  sign  that  labor  is  not  | 
far  off.  It  may,  however,  be  entirely  absent,  even  until  the  birth  of  the  - 
child.  When  copious  it  serves  to  lubricate  the  passages,  and  is  generally 
coincident  with  rapid  dilatation  of  the  parts  and  a  speedy  labor. 

False  Pains. — During  this  time  (premonitory  stage)  painful  uterine 
contractions  are  often  present,  which,  however,  have  no  effect  in  dilating 
the  cervix.  In  some  cases  they  are  frequent  and  severe,  and  are  very 
apt  to  be  mistaken  for  the  commencement  of  real  labor.  Such  '^ false 
pains,"  as  they  are  termed,  are  often  excited  and  kept  up  by  local  u-rita- 
tions,  such  as  a  loaded  or  disordered  state  of  the  intestinal  canal ;  and 
they  frequently  give  rise  to  considerable  distress  and  much  inconvenience 
both  to  the  patient  and  practitioner.  They  are,  it  should  be  remembered, 
only  the  normal  contractions  of  the  uterus,  intensified  and  accompanied 
with  pain.  •  — ■ 

MrstSta^ej^jlDilatatiori. — As  labor  actually  commences  the  uterine       j 
contractions  become  stronger,  and  the  fact  that  they  are  "true"  pains     "^ 
can  be  ascertained  by  their  effect  on  the  cervix.     If  a  vaginal  examina- 
tion be  made  during  one  of  these,  the  membranes  will  be  felt  to  become 
tense  and  bulging  during  the  pain,  and  the  os  uteri  will  be  found  par- 
tially dilated  and  thinned  at  its  edges.     As  labor  advances  this  effect  on 
the  OS  becomes  more  and  more  marked.     At  first  the  dilatation  is  very 
slight,  perhaps  not  more  than  enough  to  admit  the  tip  of  the  examining 
finger,  and  both  the  upper  and  lower  orifices  of  the  cervix  can  be  made 
out.     As  the  pains  get  stronger  and  more  frequent,  dilatation  proceeds 
in  the  way  already  described,  and  the  cervix  gets  more  thin  and  tense, 
until  we  can  feel  a  thin  circular  ring  (which  is  lax  bet^veen  the  pains, 
but  becomes  rigid  and  tense  during  the  contraction,  when  the  bag  of 
waters  bulges  through  it),  without  any  distinction  between  the  upper  and 
lower  orifices.     During  this  time  the  patient,  although  she  may  be  suffer- 
ing acutely,  is  generally  able  to  sit  up  and  walk  about.    The  amount  of  ^ 
pain  experienced  varies  much  according  to  the  character  of  the  patient.   In 
emotional  women  of  highly-developed  nervous  susceptibilities  it  is  gener- 
ally very  great.    They  are  restless,  irritable,  and  desponding,  and  when  the 
pain  comes  on  cry  out  loudly.     The  character  of  the  cry  is  peculiar  and 
well  marked  during  tlie  first  stage,  and  has  constantly  been  described  by 
obstetric  writers  as  characteristic.     It  is  acute  and  high,  and  is  certainly 
very  different  from  the  deep  groans  of  tlie  second  stage,  when  the  breath 
is  involuntarily  retained  to  assist  the  parturient  effort.    When  dilatation 
is  nearly  completed  various  reflex  nervous  phenomena  often  show  tJiem- 
selves.     One  of  these  is  nausea  and  vomiting ;  another  is  uncontrollable 
shivering,  which  is  not  accompanied  by  a  sense  of  coldness,  the  patient 
being  often  hot  and  pers])iring,     Botli  these  symjjtoms  indicate  that  the  • 
])ropulsive  stage  will   shortly  commence,  and  they  may  be  regarded  as 
favorable  rather  than   otherwise,  although  they  are  apt  to  alarm  the 
})Hti(!iit  and  her  fri(!nds.     By  this  time  the  os  is  fully  dilated,  the  mem-  j   (^ 
braiies  generally  rupture  spontaneously,  and  a  considerable  portion  of  I 
the  liquor  amnii  flows  a^vay.     The  head,  if  presenting,  often  acts  as  a      ^ 
sort  of  ball-valve,  and,  falling  down  on  the  aperture  of  the, cervix,  pre-  I 


264  LABOR. 

vents  the  complete  evacuation  of  the  liquor  amnii,  which  escapes  by 
degrees  during  the  rest  of  the  labor  or  may  be  retained  in  considerable 
quantity  until  the  birth  of  the  child. 

It  not  unfrequently  happens,  if  the  membranes  are  somewhat  tougher 
than  usual  and  the  pains  frequent  and  strong,  that  the  foetus  is  pushed 
through  the  pelvis,  and  even  expelled,  surrounded  by  the  membranes. 
When  this  occurs  the  child  is  said  to  be  born  with  a  "caul/'  and  this 
event  would  doubtless  happen  more  frequently  than  it  does  were  it  not 
the  custom  of  the  accoucheur  to  rupture  the  membranes  artificially  as 
soon  as  the  os  is  completely  opened  up,  after  which  time  their  integrity 
is  no  longer  of  any  value. 

Second  Stage,  or  Propulsion. — The  os  is  now  entirely  retracted  over 
the  presenting  part,  and  is  no  longer  to  be  felt,  the  vagina  and  the  ute- 
rine cavity  forming  a  single  canal.  Now  the  mucous  discharge  is  gener- 
ally abundant,  so  that  the  examining  finger  brings  away  long  strings  of 
glairy,  transparent  mucus,  tinged  with  blood.  The  pains,  after  a  short 
interval  of  rest,  become  entirely  altered  in  character.  The  uterus  con- 
tracts tightly  round  the  foetus,  the  presenting  part  descends  into  the  pel- 
vis, and  the  true  propulsive  pains  commence.  The^cessory  muscles  of 
parturition  now  come  into  play.  With  each  pain  the  patient  takes  a 
deep  inspiration,  and  thus  fills  the  chest,  so  as  to  give  2i  point  cV appui  to 
the  abdominal  muscles.  For  the  same  reason  she  involuntarily  seizes 
hold  of  some  point  of  support,  as  the  hand  of  a  bystander  or  a  toA\'el 
tied  to  the  bed,  and  at  the  same  time  pushes  with  her  feet  against  the 
end  of  the  bed,  and  so  is  able  to  bear  down  to  advantage.  The  cries  are 
no  longer  sharp  and  loud,  but  consist  of  a  series  of  deep  suppressed 
groans,  which  correspond  to  a  succession  of  short  expirations  made  dur- 
ing the  straining  effort.  In  this  way  the  abdominal  muscles  contract 
forcibly  on  the  uterus,  which  they  further  stimulate  to  action  by  press- 
ing upon  it.  It  is  to  be  observed  that  these  straining  efforts  are,  to  a 
considerable  extent,  under  the  control  of  the  patient.  By  encouraging 
her  to  hold  her  breath  and  bear  down  they  can  be  intensified,  while  if 
we  wish  to  lessen  them  we  can  advise  her  to  call  out,  and  when  she  does 
so  the  abdominal  muscles  have  no  longer .  a  fixed  point  of  action. 
Although  the  patient  may  thus  lessen  the  effect  of  these  accessory  mus- 
cles, it  is  entirely  out  of  her  power  to  stop  their  action  altogether.  As 
labor  advances  the  head  descends  lower  and  lower,  receding  somewhat  in 
the  intervals  between  the  pains,  until  eventually  it  comes  down  on  the 
perineum,  Avhich  it  soon  distends. 

Distendon  of  the  Perineum  and  Birth  of  the  Child. — The  pains  now 

\  get  stronger  and  more  frequent,  often  with  scarcely  a  perceptible  inter- 
val between  them,  until  the  perineum  gets  stretched  by  the  advancing 

I  head.     In  the  interval  between  the  pains  the  elasticity  of  the  perineal 

'  structures  pushes  the  head  upAvard,  so  as  to  diminish  the  tension  to 
which  the  perineum  is  subjected,  the  next  pain  again  putting  it  on  the 

.  stretch  and  protruding  the  head  a  little  farther  than  before.  By  this 
alternate  advance  and  recession  the  gradual  yielding  of  the  structures  is 

)  favored  and  risk  of  laceration  greatly  diminished.  During  this  time 
tlie  pressure  of  the  head  mechanically  empties  the  bowel  of  its  contents. 
During  the  last  pains,  when  the  perineum  is  stretched  to  the  utmost,  the 


THE  PHENOMENA   OF  LABOR.  265 

anal  aperture  is  dilated,  sometimes  to  the  size  of  a  five-shilling  piece ; 
and  in  this  way  the  perineum  is  relaxed,  just  as  the  distension,  and  con- 
sequent risk  of  laceration,  are  at  their  maximum.    The  apex  of  the  head 
now  protrudes  more  and  more  tlirough  the  vulva,  surrounded  by  the 
orifice  of  the  vagina,  and  eventually  it  glides  over  the  perineum  and  is 
expelled.    The  intensity  of  the  suffering  at  this  moment  generally  causes 
the  patient  to  call  out  loudly.     The  force  of  the  abdominal  muscles  is 
thus  lessened  at  the  last  moment ;   and  this,  in  combination  with  the 
relaxation  of  the  sphincter  ani,  forms  an  admirable  contrivance  for  less-  \ 
ening  the  risk  of  perineal  injury.     The  rest  of  the  body  is  generally  ' 
expelled  immediately  by  a  single  pain,  and  with  it  are  discharged  the  • 
remains  of  the  liquor  amnii  and  some  blood-clots  from  separation  of  the 
placenta ;  and  so  the  second  stage  of  labor  terminates.  ^ 

The  Third  Stage:  Its  Importance. — The  third  stage  commences  after  'M 
the  expulsion  of  the  child.  It  is  of  paramount  importance  to  the  safety  ^^^ 
of  the  mother  that  it  should  be  conducted  in  a  natural  and  efficient 
manner,  for  it  is  now  that  the  uterine  sinuses  are  closed ;  and  the  frail 
barrier  by  which  nature  effects  this  may  be  very  readily  interfered  with, 
and  serious  and  even  fatal  loss  of  blood  ensue.  Unfortunately,  it  is  too 
often  the  case  that  the  practitioner's  entire  attention  is  fixed  on  the  ex- 
pulsion of  the  child,  so  that  the  natural  history  of  the  rest  of  delivery  is 
generally  imperfectly  studied  and  understood. 

Contraction  of  the  Uterus  and  Detachment  of  the  Placenta. — As  soon 
as  the  child  is  expelled  the  uterine  fibres  contract  in  all  directions,  and  \ 
the  hand,  following  the  uterus  down,  will  find  that  it  forms  a  firm  rounded  • 
mass  lying  in  the  lower  part  of  the  abdominal  cavity.     By  retraction  of  I 
its  internal  surface  the  placental  attachments  are  generally  separated,  and 
the  after-birth  remains  in  the  cavity  of  the  uterus  as  a  foreign  body. 

Mode  in  which  Hemorrhage  is  Prevented. — The  escape  of  blood  from 
the  open  mouths  of  the  uterine  sinuses  is  now  prevented  in  two  ways — 
viz.  (1)  by  the  contractions  of  the  uterine  walls,  and  the  more  firm,  per-  hU-Ju*^ 

sistent,  and  tonic  this  is  the  more  certain  is  the  immunity  from  hemor-     -t- " 

rhage ;   (2)  by  the  formation  of  coagula  in  the  mouths  of  the  vessels.  (■2.i-^*X^*' 
Any  undue  haste  in  promoting  the  expulsion  of  the  placenta  tends  to 
prevent  the  latter  of  these  two  hsemostatic  safeguards,  and  is  apt  to  be 
followed  by  loss  of  blood.     After  a  certain  time,  averaging  from  a  | 
quarter  to  half  an  hour,  the  uterus  will  be  felt  to  harden,  and,  if  the  ; 
case  be  solely  left  to  nature,  what  has  been  aptly  called  a  miniature  ' 
labor  occurs.    Pains  come  on,  and  the  placenta  is  spontaneously  expelled  | 
from  the  uterus,  either  into  the  canal  of  the  vagina  or  even  externally.  ( 
In  most  obstetric  works  it  is  stated  that  the  after-birth  may  be  sepa- 
rated either  from  its    centre   or  edge,  and   that  it  is  very  generally 
expelled  through  the  os  in  an  inverted  form,  with  its  foetal  surface 
downward,  and  folded  transversely  on  itself     That  this  is  the  mode  in 
wliicli  tlie  placenta  is  often  expelled  when  traction  on  the  cord  is  jirac- 
tised  is  a  matter  of  certainty.     It  then  passes  through  the  os  very  inucli 
in  tlie  shape  of  an  inverted  uml)rella.     It  is  certain,  however,  that  this  is 
not  the  natural  meclianism  of  its  delivery.     What  this  is  has  bcsen  well 
illustrated  by  Duncan,'  w1)(j  has  very  clearly  shown  that  wdien  this  stage 

1  Edin.  Med.  Journ.,  April,  1871. 


tft*j*^ 


266 


LAB  OB. 


Mode  in  which  the  Pla- 
centa is  Naturally  Ex- 
pelled. (After  Duncan.) 


of  labor  is  left  entirely  to  nature  the  separated  placenta  is  expelled  edge- 
ways, its  uterine  and  detached  surface  gliding  along  the  inner  surface  of 
the  uterus,  the  foldings  of  its  structure  being  parallel  to  the  long  diameter 
of  the  uterine  cavity  (Fig.  96).  In  this  May  it  is 
expelled  into  the  vagina,  and  during  the  process 
little  or  no  hemorrhage  occurs.  When  the  pla- 
centa is  drawn  out  in  the  way  too  generally  prac- 
tised, it  obstructs  the  aperture  of  the  os,  and,  acting 
like  the  piston  of  a  pump,  tends  to  promote  hem- 
orrhage. The  corollaries  as  to  treatment  drawn 
from  these  facts  will  be  subsequently  considered. 
I  am  anxious,  however,  here  to  direct  attention 
to  Nature's  mechanism,  because  I  believe  there  is 
no  part  of  labor  about  the  management  of  which 
erroneous  views  are  more  prevalent  than  that  of  this 
stage,  and  none  in  which  they  are  more  apt  to  lead 
to  serious  consequences ;  and  unless  the  mode  in 
which  Nature  effects  the  expulsion  of  the  placenta 
and  prevents  hemorrhage  is  thoroughly  understood, 
we  shall  certainly  fail  in  assisting  her  in  a  proper 
manner.  In  the  large  proportion  of  cases,  when  left 
entirely  to  themselves,  the  placenta  would  be  re- 
tained, if  not  in  the  uterus,  at  any  rate  in  the  vagi- 
na, for  a  considerable  time — possibly  for  several  hours ;  and  such  delay 
would  very  unnecessarily  tire  the  patience  of  the  practitioner  and  be  pre- 
judicial to  the  patient.  It  is  therefore  our  duty  in  the  majority  of  cases 
to  promote  the  expulsion  of  the  after-birth ;  and  when  this  is  properly 
and  scientifically  done  we  increase  rather  than  diminish  the  jjatient's  safety 
and  comfort.  But  in  order  to  do  this  we  must  assist  Nature,  and  not 
act  in  opposition  to  her  method,  as  is  so  often  the  case. 

After-Pains. — When  once  the  placenta  is  expelled,  the  uterus  con- 
tracts still  more  firmly,  and  in  a  typical  case  is  felt  just  within  the 
pelvic  brim,  hard  and  firm  and  about  the  size  of  a  cricket-ball.  Gen- 
erally for  several  hours,  or  even  for  one  or  two  days,  it  occasionally 
relaxes  and  contracts,  and  these  contractions  give  rise  to  the  "  after- 
jxtins"  from  which  women  ofiten  suffer  much.  The  object  of  these 
pains  is,  no  doubt,  to  expel  any  coagula  that  may  remain  in  the  uterus ; 
and  therefore,  however  unpleasant  they  may  be  to  the  patient,  they  must 
be  considered,  unless  very  excessive,  to  be  salutary  rather  than  otherwise. 
Duration  of  Labor. — The  length  of  labor  varies  extremely  in  differ- 
ent cases,  and  it  is  quite  impossible  to  lay  down  any  definite  rules  with 
regard  to  it.  Subject  to  exceptions,  labor  is  longer  in  primiparae  than 
in  multiparse,  on  account  of  the  greater  resistance  of  the  soft  parts  in 
the  former,  especially  of  the  structures  about  the  vagina  and  vulva.  It 
is  also  generally  stated  that  the  difficulty  of  labor  increases  with  the  age 
of  the  patient,  and  that  in  elderly  primiparae  it  is  likely  to  be  unusually 
tedious  from  rigidity  of  the  soft  parts.  It  is  very  doubtful  if  this 
opinion  has  any  real  basis,  and  in  such  cases  the  practitioner  often  finds 
himself  agreeably  disappointed  in  the  result.    Mr.  Roper,^  indeed,  argues 

1  Obst.  Trans.,  v.  7. 


THE  PHENOMENA   OF  LABOR.  267 

that  the  wasting  of  the  tissues  which  occurs  after  forty  years  of  age  | 
diminishes  their  resistance,  and  that  first  labors  after  that  age  are  easier,  ; 
as  a  rule,  than  in  early  life.     The  habits  and  mode  of  life  of  patients 
have  no  doubt  a  considerable  influence  on  the  duration  of  labor,  but  we 
are  not  in  possession  of  any  very  reliable  facts  with  regard  to  this  sub- 
ject.    It  is  reasonable  to  suppose  that  the  tissues  of  large,  muscular, 
strongly-developed  women  will    offer   more  resistance   than  those   of 
slighter  build.    On  the  other  hand,  women  of  the  latter  class,  especially 
in  the  upper  ranks  of  life,  more  often  develop  nervous  susceptibilities 
which  may  be  expected  to  influence  the  length  of  their  labors.     The  j 
average  duration  of  labor,  calculated  from  a  large  number  of  cases,  is  ' 
from  eight  to  ten  hours ;  even  in  primiparse,  however,  it  is  constantly 
terminated  in  one  or  t^vo  hours  from  its  commencement,  and  may  b^ 
extended  to  twenty-four  hours  without  any  symptoms  of  urgency  aris-  , 
ing.     In  multiparse  it  is  frequently  over  in  even  a  shorter  time.     Indi- 
cations calling  for  interference  may  arise  at  any  time  during  the  progress 
of  labor  independently  of  its  length.    The  proportion  between  the  length  '\ 
of  the  first  and  second  stages  also  varies  considerably.     The  first  stage  i 
is  generally  the  longest ;  and  it  is  stated  by  Cazeaux  to  be  normally 
about  twice  the  lengtli  of  the  second.    This  is  probably  under  the  mark, 
and  I  believe  Joulin  to  be  nearer  the  truth  in  stating  that  the  first  stage  ' 
should  be  to  the  second  as  four  or  five  to  one,  rather  than  as  two  to  one.  I 
Often  when  the  first  stage  has  been  very  prolonged  the  second  is  termi-  ' 
natecl  rapidly. 

Necessity  of  Caution  in  Expressing  an  Opinion  as  to  the  Possible  Dura- 
tion of  Labor. — The  practitioner  is  constantly  asked  as  to  the  probable 
length  of  labor,  and  the  uncertainty  of  this  should  always  lead  him  to 
give  a  most  guarded  opinion.  Even  when  labor  is  progressing  appar- 
ently in  the  most  satisfactory  manner,  the  pains  frequently  die  away  and 
delivery  may  be  delayed  for  many  hours.  In  the  first  stage  a  cervix 
that  is  apparently  rigid  and  unyielding  may  rapidly  and  unexpectedly 
dilate  and  delivery  soon  follow.  In  either  case,  if  the  practitioner  has 
committed  himself  to  a  positive  opinion,  he  is  apt  to  incur  blame,  and  it 
is  far  better  always  to  be  extremely  cautious  in  our  predictions  on  this 
j)oint. 

Period  of  the  Day  at  which  Labor  Occurs. — A  somewhat  larger  pro- 
portion of  deliveries  occur  in  the  early  hours  of  the  morning  than  at 
other  times.  Thus,  West'  found  that  out  of  2019  deliveries,  780  took 
place  from  lip.  m.  to  7  A.  M.,  662  from  Z  A.  m,  to  3  p.  m.,  and  577  from 
3  P.M.  to  11  P.M. 

'  Amer.  Med.  Journ.,  1854. 


268  LABOR. 


CHAPTER  II. 

MECHANISM  OF  DELIVERY  IN  HEAD  PEESENTATIONS. 

Im-portance  of  the  Subject. — It  is  quite  impossible  to  over-estimate  the 
importance  of  thoroughly  understanding  the  mechanism  of  the  passage 
of  the  foetus  through  the  pelvis.  This  dominates  the  whole  scientific 
practice  of  midwifery,  and  the  practitioner  cannot  acquire  more  than  a 
merely  empirical  knowledge,  such  as  may  be  possessed  by  an  uneducated 
midwife,  or  conduct  the  more  difficult  cases  requiring  operative  interfer- 
ence with  safety  to  the  patient  or  satisfaction  to  himself,  unless  he  thor- 
oughly masters  the  subject. 

In  treating  the  physiological  phenomena  of  labor  it  was  assumed  that 
we  had  to  do  with  an  ordinary  case  of  head  presentation,  the  description 
being  applicable,  with  slight  variations,  to  presentations  of  other  parts 
of  the  Ibetus.  So  in  discussing  the  mechanical  phenomena  of  delivery 
I  shall  describe  more  in  detail  the  mechanism  of  head  presentations, 
reserving  any  account  of  the  mechanism  of  other  presentations  until  they 
are  separately  studied. 

Frequency  of  Head  Presentation.'^. — Head  presentation  is  so  much  more 
frequent  than  that  of  any  other  part — amounting  to  95  per  cent,  of  all 
cases — that  this  mode  of  studying  the  subject  is  fully  justified  ;  and 
when  once  the  student  has  mastered  the  phenomena  of  delivery  in  head 
presentations,  he  will  have  little  difficulty  in  understanding  the  mechan- 
ism when  other  parts  of  the  foetus  present,  based,  as  it  always  is,  on  the 
same  general  plan. 

Mode  of  Recognizing  the  Position  of  the  Head  by  its  Sutu7'es  and  Fon- 
taneUes. — In  entering  on  this  study  we  come  to  appreciate  the  importance 
of  the  sutures  and  fontanelles  in  enabling  us  to  detect  the  position  of  the 
foetal  head  and  to  watch  its  progress  through  the  pelvis ;  and  unless  the 
"tactus  eruditus"  by  which  these  can  be  distinguished  from  each  other 
has  been  acquired,  the  practitioner  will  be  unable  to  satisfy  himself  of 
the  exact  progress  of  the  labor.  Nor  is  this  always  easy.  Indeed,  it 
requires  considerable  experience  and  practice  before  it  is  possible  to  make 
out  the  position  of  the  head  with  absolute  certainty ;  but  this  knowledge 
should  always  be  aimed  at,  and  the  student  will  never  regret  the  time 
and  trouble  he  spends  in  acquiring  it. 

Position  of  the  Head  at  the  Commencement  of  Labor. — At  the  com- 
mencement of  labor  the  long  diameter  of  the  head  lies  in  almost  any 
diameter  of  the  pelvic  brim  except  in  the  antero-posterior,  where  there 
is  not  space  for  it.  In  the  large  majority  of  cases,  however,  it  enters 
the  pelvis  in  one  or  other  of  the  oblique  diameters,  or  in  one  between  the 
oblique  and  transverse ;  but  until  it  has  fairly  passed  through  the  brim 
it  more  frequently  lies  directly  in  the  transverse  diameter  than  has  been 
generally  supposed.  Hence  obstetricians  are  in  the  habit  of  describing 
the  head  as  lying  in  four  positions,  according  to  the  parts  of  the  pelvis 


DELIVERY  IN  HEAD  PRESENTATIONS. 


269 


to  which  the  occiput  points ;  the  first  and  third  positions  being  those  in 
which  the  long  diameter  of  the  head  occupies  the  right  oblique  diameter 
of  the  pelvis,  the  second  and  fourth  those  in  which  it  lies  in  the  left 
oblique.  Many  subdivisions  of  these  positions  have  been  made,  which 
only  complicate  the  subject  and  render  it  more  difficult  to  understand. 

The  positions,  then,  of  the  foetal  head  after  it  has  entered  the  brim, 
which  it  is  of  importance  to  be  able  to  distinguish  in  practice,  are : 

First  {or  left  occipito-eotyloid). — The  occiput  points  to  the  left  for- 
amen ovale,  the  sinciput  to  the  right  sacro-iliac  synchondrosis,  and 
the  long  diameter  of  the  head  lies  in  the  right  oblique  diameter  of  the 
pelvis. 

Second  (or  right  occipito-eotyloid). — The  occiput  points  to  the  right 
foramen  ovale,  the  forehead  to  the  left  sacro-iliac  synchondrosis,  and 
the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the 
pelvis. 

Third  (or  right  occipito-sacro-iliac). — The  occiput  points  to  the  right 
sacro-iliac  synchondrosis,  the  forehead  to  the  left  foramen  ovale,  and  the 
long  diameter  of  the  head  lies  in  the  right  oblique  diameter  of  the  pelvis. 
This  position  is  the  reverse  of  the  first. 

Fourth  [or  left  occipito-sacro-iliac). — The  occiput  points  to  the  left 
sacro-iliac  synchondrosis,  the  forehead  to  the  right  foramen  ovale,  and 
the  long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the  pel- 
vis.    This  position  is  the  reverse  of  the  second. 

The  Relative  Frequency  of  these  Positions.- — The  relative  frequency  of 
these  positions  has  long  been,  and  still  is,  a  matter  of  discussion  among 
obstetricians.  According  to  Naegele,  to  whose  classical  essay  we  owe 
the  greater  part  of  our  knowledge  of  the  subject,  the  head  lies  in  the 
right  oblique  diameter  in  99  per  cent,  of  all  cases.  More  recent 
researches  have  thrown  some  doubt  on  the  accuracy  of  these  figures,  and 
many  modern  obstetricians  believe  that  the  second  position,  which  'Nae- 
gele  believed  only  to  be  observed  as  a  transitional  stage  in  the  natural 
progress  of  the  third  position,  is  much  more  common  than  he  supposed. 
This  question  will  be  more  fully  discussed  when  we  treat  of  the  mechan- 
ism of  occipito-posterior  delivery,  and,  in  the  mean  time,  it  may  serve 
to  show  the  discrepancy  which  exists  in  the  opinions  of  modern  writers 
if  we  append  the  following  table  of  the  relative  frequency  of  the  various 
positions,^  copied  from  Leishman's  work : 


Naegele 

Naegele,  Jr 

Simpson  and  Barry 

Dubois 

Murphy 

Swayne 


First 

Second 

Tliird 

Fourth 

Not        ! 

Position. 

Position. 

Position. 

Position. 

Classified. 

70. 

29. 

1. 

64.64 

32.88 

2.47 

76.45 

.29 

22.68 

.58 

70.83 

2.87 

25.66 

.62 

63.23 

16.18 

16.18 

4.42 

86.36 

9.79 

1.04 

2.8 

Here  it  will  be  seen  that  all  obstetricians  are  agreed  as  to  the  immensely 
greater  frequency  of  the  first  position,  the  only  point  at  issue  being  the 
relative  frequency  of  the  second  and  third. 

^  Leishman's  Syntem  of  Midwifery,  p.  341. 


U. 


1^-0. 


Ii.O. 


270  LABOR. 

Explanation. — Various  explanations  have  been  given  of  the  greater 
frequency  with  which  the  liead  lies  in  the  right  oblique  diameter.  By- 
some  it  is  referred  to  the  natural  tendency  of  the  back  of  the  foetus,  as 
shown  by  the  experimental  researches  of  Honing  and  other  writers,  to 
be  directed,  in  consequence  of  gravitation,  forward  and  to  the  left  side 
of  the  mother  in  the  erect  attitude,  and  backward  and  to  her  right  side 
in  the  recumbent.  The  explanation  given  by  Simpson  was  that  the 
head  lay  in  the  right  oblique  diameter  in  consequence  of  the  measure- 
ment of  the  left  oblique  being  more  or  less  lessened  by  the  presence  of 
the  rectum.  When  the  rectum  is  collapsed,  indeed,  the  narrowing  of 
the  diameter  is  slight  ;  but  it  is  so  often  distended  by  fecal  matter — 
sometimes,  when  constipation  exists,  to  a  very  great  extent — that  it  may 
really  have  a  very  important  influence  in  determining  the  position  of  the 
foetal  head. 

In  describing  the  mechanism  of  delivery  it  will  be  well  for  us  to  con- 
centrate our  attention  on  the  first  or  most  common  position,  dwelling 
subsequently  more  briefly  on  the  differences  between  it  and  the  less 
common  ones. 

Description  of  the  First  Position. — In  this  position,  when  the  head 
commences  to  descend,  the  occiput  lies  in  the  brim  pointing  to  the  left 
ileo-pectineal  eminence,  the  forehead  is  directed  to  the  right  sacro-iliac 
synchondrosis,  and  the  sagittal  suture  runs  obliquely  across  the  pelvis  in 
the  right-oblique  diameter.     The  back  of  the  child  is  turning  toward 


Fig.  9 


Attitude  of  Child  in  First  Position.    (After  Hodge.) 

the  left  side  of  the  mother's  abdomen,  the  right  shoulder  to  her  right 
side,  the  left  to  her  left  side  (Fig.  97).  If  a  vaginal  examination  be 
now  made  (the  patient  lying  in  the  ordinary  obstetric  position),  and  the 
OS  be  sufficiently  open,  the  finger  will  impinge  upon  the  protuberance  of 
the  right  parietal  bone,  which  is  described  as  the  "  presenting  part " — a 


DELIVERY  IN  HEAD  PRESENTATIONS. 


271 


term  which  has  received  various  definitions,  the  best  of  which  is  proba- 
bly that  adopted  by  Tyler  Smith  :  viz.  "  that  portion  of  the  foetal  head 
felt  most  prominently  within  the  circle  of  the  os  uteri,  the  vagina,  and 
the  OS  tincse  in  the  successive  stages  of  labor."  If  the  tip  of  the  exam- 
ining finger  be  passed  slightly  upward,  it  will  feel  the  sagittal  suture 
running  obliquely  across  the  pelvis,  and  if  this  be  traced  downward  and 
to  the  left,  it  will  come  upon  the  triangular  posterior  fontanelle,  with  the 
lambdoiclal  sutures  diverging  from  it.  If  the  finger  could  be  passed 
sufficiently  high  in  the  opposite  direction,  upward  and  to  the  right,  it 
would  come  upon  the  large  anterior  fontanelle,  but  at  this  time  that  is 
too  high  up  to  be  within  reach.  The  chin  is  slightly  flexed  upon  the 
sternum,  this  flexion,  as  we  shall  presently  see,  being  greatly  increased 
as  the  head  begins  to  descend. 

The  head,  at  the  commencement  of  labor,  generally  lies  within  the 
pelvic    brim,  especially  in    primiparse.     In  multiparse,    owing   to   the 

Fig.  98. 


First  Position  :  Movement  of  Flexion. 

relaxation  of  the  abdominal  parietes,  the  uterus  is  apt  to  fall  somewhat 
forward,  and  the  head  consequently  is  more  entirely  above  the  brim,  but 
is  pushed  within  it  as  soon  as  labor  actually  commences. 

Naegele's  Vieivs. — Naegele — and  his  description  has  been  adopted  by 
most  subsequent  writers — describes  the  head  at  this  period  as  lying 
obliquely  in  relation  to  the  brim,  the  right  parietal  bone,  on  which  the 
examining  finger  impinges,  being  supposed  by  him  to  be  much  lower 
than  the  left.  The  accuracy  of  this  view  has  of  late  years  been  con- 
tested, and  it  is  now  pretty  generally  admitted  that  this  obll(]uity  does 
not  exist,  and  that  the  head  enters  the  brim  of  the  pelvis  with  both 
parietal  bones  on  the  same  level,  and  with  its  bi-jiarietal  diameter  par- 
allel to  the  plane  of  the  inlet  (Fig.  98).  Naegele's  view  was  adopted, 
partly  because  the  finger  always  felt  the  right  parietal  protuberance  low- 
est, and  partly  ])ecause  it  was  at  that  jioint  tliat  the  "  caput  succe- 
dancum,"  or  s\vel]ing  ob.served  on  the  head  after  delivery,  was  ahvays 


272  LABOR. 

formed.  Both  arguments  are,  however,  fallacious ;  for  the  right  pari- 
etal bone  is  the  part  which  would  naturally  be  felt  lowest,  on  account 
of  the  oblique  position  of  the  pelvis  to  the  trunk  ;  while,  with  regard  to 
the  caput  succedaneum,  it  has  been  conclusively  proved  by  Duncan  that 
it  does  not  form  on  the  point  most  exposed  to  pressure,  as  Naegele 
assumed,  but  on  the  part  of  the  head  where  there  is  least  pressure — that 
is,  the  part  lying  over  the  axis  of  the  vaginal  canal. 

Division  of  3Ieehanical  Movements  into  Stages. — In  tracing  the  prog- 
ress of  the  head  from  the  position  just  described,  obstetricians  have  been 
in  the  habit  of  dividing  the  movements  it  undergoes  into  various  stages, 
which  are  convenient  for  the  purpose  of  facilitating  description.  It 
must  be  borne  in  mind  that  these  are  not  evident  and  distinct  stages, 
which  can  always  be  made  out  in  practice,  but  that  they  run  insensibly 
into  one  another,  and  often  occur  simultaneously,  or  nearly  so,  in  rapid 
labor.  They  may  be  described  as — 1.  Flexion;  2.  First  movement  of 
descent ;  3.  Levelling  or  adjusting  movement ;  4.  Rotation ;  5.  Second 
'  ^  movement  of  descent  and  extension  ;  6.  External  rotation. 
►-^'  .  1.  Flexion. — The  first  movement  of  the  head  consists  of  a  rotation  on 

its  bi-parietal  diameter,  by  which  the  chin  of  the  child  becomes  bent  on 
^^^  ,,  the  sternum  and  the  occiput  descends  lower  than  the  forehead.  By  this 
;  there  is  a  clear  gain  of  at  least  a  half  inch,  for  the  occipito-bregmatic 

^S%)    diameter  (3|-  inches)  becomes  substituted  for  the  occipito-frontal  (4|^ 
inches)  (Fig.  98). 

The  movement  is  most  marked  when  the  pelvis  is  narrow,  and  in 
some  cases  of  pelvic  deformity  it  takes  place  to  an  extreme  degree ; 
while  in  unusually  large  and  roomy  pelves  it  occurs  to  a  very  slight 
extent  or  not  at  all.  The  reason  of  this  flexion  is  twofold.  Solayres 
and  the  majority  of  obstetricians  explain  it  by  saying  that  the  expulsive 
force  is  communicated  to  the  head  through  the  vertebral  column,  and 
inasmuch  as  the  head  is  articulated  much  nearer  the  occiput  than  the 
sinciput,  the  resistance  being  equal,  the  former  must  be  pushed  down. 
This  is  doubtless  the  correct  explanation  of  the  flexion  after  the  mem- 
branes are  ruptured ;  but  before  that  happens  the  ovum  is  practically  a 
bag  of  water,  which  is  equally  compressed  at  all  points  by  the  uterine 
contraction,  and  is  pushed  downward  through  the  os  en  masse,  the  expul- 
sive force  not  being  transmitted  through  the  vertebral  column  at  all. 
Under  such  circumstances  flexion  is  probably  effected  in  the  following 
way :  the  head  being  articulated  nearer  the  occiput  than  the  forehead, 
and  being  equally  pressed  upon  from  below  by  the  resisting  structures, 
the  pressure  is  more  effectual  on  the  forehead ;  consequently,  that  is 
forced  upward  and  the  occiput  descends.  This  explanation  would  also 
hold  good  after  the  rupture  of  the  membranes,  and  probably  both  causes 
assist  in  effecting  the  movement. 

2  and  3.  Descent  and  Levelling  Movement. — The  movements  of  descent 
and  levelling  may  be  described  together.  As  soon  as  the  head  is  liberated 
from  the  os  uteri,  it  descends  pretty  rapidly  through  the  pelvis  until  the 
occiput  reaches  a  point  nearly  opposite  the  lower  part  of  the  foramen 
ovale  (Fig.  99)  and  the  sinciput  is  opposite  the  second  bone  of  the 
sacrum.  A  levelling  movement  now  occurs  ;  the  anterior  fontanelle 
comes  to  be  more  easily  within  reach,  more  on  a  level  with  the  posterior, 


DELIVERY  IN  HEAD  PRESENTATIONS. 


273 


and  the  chin  is  no  longer  so  mnch  flexed  on  the  sternum.  Tliis  change 
is  due  to  the  fact  that  the  anterior  end  of  the  ovoid  experiences  greater 
resistance  than  the  posterior,  and  as  soon  as  this  resistance  counterbal- 
ances and  exceeds  that  applied  to  the  latter,  the  sinciput  must  descend. 
The  right  side  of  the  head  also  descends  more  than  the  left  from  a  sim- 
ilar cause,  so  that  the  head  becomes,  as  it  were,  slightly  flexed  on  the 
right  shoulder.     This  obliquity  of  the  head  on  its  transverse  diameter 

Fig.  99. 


First  Position :  Occiput  in  the  Cavity  of  ttie  Pelvis.    (After  Hodge.) 

in  the  lower  part  of  the  pelvis  has  been  denied  by  Kuneke,^  who  main- 
tains that  the  head  passes  through  the  entire  pelvis  in  the  same  position 
as  it  enters  the  brim — that  is,  with  both  parietal  bones  on  a  level — so 
that  the  point  of  intersection  of  the  transverse  and  antero-posterior 
diameters  of  the  pelvis  would  correspond  with  the  sagittal  suture.  There 
is,  however,  good  reason  to  believe  that  in  the  lower  half  of  the  pelvic 
cavity  the  head  is  not  truly  synclitic,  as  Kiineke  describes,  but  that  the 
right  parietal  bone  is  on  a  somewhat  lower  level  than  the  left. 

4.  Rotation. — The  movement  of  rotation  is  very  important.  By  it 
the  long  diameter  of  the  head  is  changed  from  the  oblique  diameter  of 
the  pelvic  cavity  to  the  antero-posterior  diameter  of  the  outlet  (Fig.  100), 

Fig.  100. 


First  Position :  Occiput  at  Outlet  of  the  Pelvis.    (After  Hodge.) 

or  to  a  diameter  nearly  corresponding  to  it,  so  that  the  long  diameter  of 
the  head  is  brought  into  relation  with  the  longest  diameter  of  the  pelvic 
outlet.  This  alteration  almost  always  takes  place,  and  may  be  readily 
observed  by  the  accoucheur  who  carefully  watches  the  ])rogress  of  labor. 
Various  exjilanations  have  been  given  of  its  causes.  The  one  most  gen- 
erally adopted  is,  that  it  is  due  to  tlie  ])r()j('('tion  inward  of  the  is(;hial 
spines,  which  narrow  the  transverse  diameter  of  the  pelvic  outlet.     As 

'  Die  Vier  FarAnren  der  Geburi,  Berlin,  18G9. 
18 


274  LABOR. 

the  pains  force  the  occiput  downward,  its  rotation  backward  is  prevented 
by  the  projection  of  the  left  ischial  spine,  while  its  rotation  forward  is 
favored  by  the  smooth  bevelled  surface  of  the  ascending  ranms  of  the 
ischium.  Similarly,  the  ischial  spine  on  the  opposite  side  prevents  the 
rotation  forward  of  the  forehead,  which  is  guided  backward  to  the  cavity 
of  the  sacrum  by  the  smooth  surface  of  the  sacro-ischiatic  ligaments. 
These  arrangements,  therefore,  give  a  screw-like  form  to  the  interior  of 
the  pelvis  ;  and  as  the  pains  force  the  head  downward,  they  are  eifectual 
in  imparting  to  it  the  rotatory  movement  which  is  of  such  importance  in 
adapting  it  to  the  longest  measurement  of  the  outlet. 

By  most  of  the  German  obstetricians  the  influence  of  the  ischial  spines 
and  of  the  smooth  pelvic  planes  in  producing  rotation  is  not  admitted. 
I  They  rather  refer  the  change  of  direction  to  the  increased  resistance  the 
I  head  meets  from  the  posterior  wall  of  the  pelvis  and  from  the  perineal 
\  structures.     Whichever  part  of  the  head  first  meets  this  resistance,  which 
""is  much  greater  than  that  of  the  interior  part  of  the  pelvis,  must  neces- 
sarily be  pressed  forward ;  and  as,  in  the  large  majority  of  cases,  the 
posterior  fbntanelle  descends  first,  it  is  thus  pressed  forward  until  rota- 
tion is  effected.     This  view  has  the  advantage  of  accounting  equally  Avell 
for  the  rotation  in  occipito-posterior  as  in  occipito-anterior  positions,  the 
former  of  which,  on  the  more  ordinarily  received  theory,  are  not  quite 
satisfactorily  explicable.     It  does  not  follow  that  the  smooth  surfaces  of 
the  pelvic  planes  are  without  influence  in  favoring  the  rotation — on  the 
contrary,  they  probably  greatly  facilitate  it — but  it  is  more  simply  and 
effectually  explained  by  the  latter  theory  than  by  that  which  attributes 
so  important  an  action  to  the  ischial  spines. 

In  some  rare  cases  the  head  escapes  rotation  and  reaches  the  perineum 
still  lying  in  the  oblique  diameter.  Even  here,  however,  rotation  is  gen- 
erally effected,  often  suddenly,  just  as  the  head  is  about  to  pass  the  vulva, 
and  it  is  very  rarely  expelled  in  the  oblique  position.  The  movement 
at  this  stage  may  be  explained  by  the  perineum,  which  is  attached  at  its 
sides  and  grooved  in  its  centre :  to  the  hollow  so  formed  the  long  diam- 
eter of  the  head  accommodates  itself,  and  is  thus  rotated  into  the  antero- 
posterior diameter  of  the  outlet. 

5.  Extension. — By  the  process  just  described  the  face  is  turned  back 
•  into  the  hollow  of  the  sacrum ;  but  the  head  does  not  lie  absolutely  in 
the  antero-posterior  diameter  of  the  pelvic  outlet,  but  rather  in  one 
between  it  and  the  oblique.  The  occiput  is  still  forced  down  by  the 
pains,  and,  in  consequence  of  its  altered  position,  is  enabled  to  pass 
between  the  rami  of  the  pubes,  and  advances  until  its  further  descent  is 
checked  by  the  nape  of  the  neck,  which  is  pressed  under  and  against  the 
arch  of  the  pubes.  By  this  means  the  occiput  is  fixed,  and,  the  pains 
continuing,  the  uterine  force  no  longer  acts  on  the  occiput,  but  on  the 
anterior  part  of  the  head,  which  is  now  pushed  down  and  separated  from 
the  sternum.  This  constitutes  extension.  As  the  head  descends  the  soft 
structures  of  the  perineum  are  stretched  and  the  coccyx  pushed  back  so 
as  to  enlarge  the  outlet.  The  pains  continue  to  distend  the  perineum 
more  and  more,  the  head  advancing  and  receding  with  each  pain.  As 
the  forehead  descends,  the  sub-occipito-bregmatic,  the  sub-occipito- 
frontal,  and  the  sub-occipito-mental  diameters  successively  present ;  the 


DELIVER Y  IN  HEAD  PRESENTATIONS. 


275 


occiput  turns  more  and  more  upward  in  front  of  the  pubes  (Fig.  101), 
and  at  last  the  face  sweeps  over  the  perineum  and  is  born. 

The  mechanical  cause  of  this  movement  may  be  readily  explained. 
As  soon  as  the  occiput  has  passed  under  the  arch  of  the  pubis,  and  is 


Fig.  101. 


First  Position  :  Head  Delivered.    (After  Hodge.) 

no  longer  resisted  by  the  anterior  pelvic  walls,  the  head  is  subjected  to 
the  action  of  two  forces — that  of  the  uterine  pressure,  acting  downward 
and  backward,  and  that  of  the  resistance  of  the  posterior  walls  of  the 
pelvis  and  the  soft  parts,  acting  almost  directly  forward.  The  necessary 
result  is  that  the  head  is  pushed  in  a  direction  intermediate  between  these 
two  opposing  forces — that  is,  downward  and  forward  in  the  axis  of  the 
pelvic  outlet. 

In  addition  to  the  slight  obliquity  which  exists  as  regards  the  direct 
relation  of  the  long  diameter  of  the  head  to  the  antero-posterior  diameter 
of  the  outlet  at  the  moment  of  its  expulsion,  the  head  also  lies  somewhat 
obliquely  in  relation  to  its  own  transverse  diameter,  so  that,  in  the 
majority  of  cases,  the  right  parietal  bone  is  expelled  before  the  left. 

Fig.  102. 


External  liotation  ol'  Jlend  in  First  Fosition.    (After  Hodge.) 

6.  Exfenidl  Rof/ifiov. — Shortly  after  the  head  is  expelled,  as  soon  as 
renewed  uteriiK!  action  coinnienccs,  it  mny  be  observed  to  make  a  dis- 
tinct rotatory  mov(!ni(!nt,  the  oc('i])iit  turning  to  tlu;  hit  thigh  of  the 
mother,  and  the  face  turning  upward  to  the  right  thigh  (Fig.  102).    The 


276 


LABOR. 


reason  of  this  is  evident.  When  the  liead  descends  in  the  right  oblique 
diameter,  the  shoulders  lie  in  the  opposite  or  left  oblique  diameter,  and  as 
the  head  rotates  into  the  antero-posterior  diameter  they  are  necessarily 
placed  more  nearly  in  the  transverse.  As  soon  as  the  head  is  expelled  the 
shoulders  are  subjected  to  the  same  uterine  force  and  pelvic  resistance  as 
the  head  has  just  been,  and  they  are  acted  on  in  precisely  the  same  way. 
Consequently  they  too  rotate,  but  in  the  opposite  direction — into  the 
antero-posterior  diameter  of  the  outlet,  or  nearly  so,  just  as  the  head  did — 
and  as  they  do  so  they  necessarily  carry  the  head  with  them  and  cause 
its  external  rotation. 

The  two  shoulders  are  soon  expelled,  the  left  shoulder  generally  the 
first,  sweeping  over  the  perineum  in  the  same  manner  as  the  face.  This 
is,  however,  not  always  the  case,  and  they  are  often  expelled  simulta- 


FiG.  103. 


Third  Position  of  Occiput  at  Brim  of  Pelvis. 

neously,  or  the  right  shoulder  may  come  first.  The  body  soon  follows ; 
and  the  second  stage  of  labor  is  completed. 

Second  Position. — In  the  second  position  (right  occipito-cotyloid)  the 
long  diameter  of  the  head  lies  in  the  left  oblique  diameter  of  the  pelvis. 
On  making  a  vaginal  examination  in  the  ordinary  obstetric  position,  the 
finger,  passing  up\^'ard  and  to  the  right,  feels  the  small  posterior  fonta- 
nelle;  downward  and  to  the  left,  it  feels  the  anterior.  The  sagittal 
suture  lies  obliquely  across  the  pelvis  in  the  left  oblique  diameter.  The 
description  of  the  mechanism  of  delivery  is  precisely  the  same  as  in  the 
first  position,  substituting  the  word  left  for  right.  Thus  the  finger 
impinges  on  the  left  parietal  bone ;  the  occiput  turns  from  right  to  left 
during  rotation.  After  the  birth  of  the  head  the  occiput  turns  to  the 
right  thigh  of  the  mother,  the  face  to  the  left  thigh. 

Third  or  Right  Occipito-sacro-iJiac  Position. — In  the  third  position 
the  head  enters  the  pelvic  brim  AA'ith  the  occiput  directed  backward  to 
the  right  sacro-iliac  synchondrosis,  and  the  sinciput  forward  to  the  left 
foramen  ovale  (Fig.  103).     The  posterior  fontanelle  is  directed  back- 


DELIVERY  IN  HEAD  PRESENTATIONS.  277 

ward,  the  anterior  fontanelle  forward,  while  the  examining  finger  im- 
pinges on  the  left  parietal  bone.  The  mechanism  of  delivery  in  these 
cases  is  of  much  interest.  In  the  large  majority  of  cases,  during  the 
progress  of  delivery  the  occiput  rotates  forward  along  the  right  side  of 
the  pelvis  until  it  comes  to  lie  almost  in  the  antero-posterior  diameter  of 
the  outlet  and  passes  under  the  pubic  arch,  the  forehead  passing  over  the 
perineum.  It  will  be  seen  that  during  part  of  this  extensive  rotation 
the  head  must  lie  in  the  second  position,  and  the  case  terminates  just  as 
if  it  had  been  in  the  second  position  from  the  commencement  of  labor. 

Manner  in  which  the  Occiput  is  Rotated  Forward. — How  is  it  that 
this  rotation  is  effected,  and  that  the  sinciput,  occupying  the  position  of 
the  occiput  in  the  first  position,  should  not  be  rotated  forward  to  the 
pubes  as  that  is  ?  This,  no  doubt,  may  be  explained  by  the  fact  that  the 
uterine  force  transmitted  through  the  vertebral  column  causes  the  occiput 
to  descend  lower  than  the  sinciput,  so  that  in  most  cases,  in  making  a 
vaginal  examination,  the  posterior  fontanelle  can  be  readily  felt,  while 
the  anterior  is  high  up  and  out  of  reach.  The  head  is  therefore  extremely 
flexed,  and  so  descends  into  the  pelvic  cavity,  until  the  occiput,  being 
now  below  the  right  ischial  spine,  experiences  the  resistance  of  the  pelvic 
floor  opposite  the  right  sacro-ischiatic  ligament,  by  which  it  is  directed 
forward.  The  forehead  is  at  this  time,  supposing  flexion  to  be  marked, 
too  high  to  be  influenced  by  the  anterior  pelvic  plane.  Pressure  continu- 
ing, the  occiput  rotates  forward,  the  forehead  passes  round  the  left  side 
of  the  pelvis,  and  labor  is  terminated  as  in  the  second  position. 

The  period  of  labor  at  which  rotation  takes  place  varies.     In  the 
majority  of  cases  it  does  not  occur  until  the  head  is  on  the  floor  of  the 
pelvis,  for  it  is  then^  that  resistance  is  most  felt ;  but  the  greater  the 
resistance,  the  sooner  will  rotation  be  produced.     Hence  it  is  more  likely' 
to  occur  early  when  the  head  is  large  and  the  pelvis  comparatively  small. 

The  facility  with  which  this  movement  is  effected  obviously  depends 
upon  the  complete  flexion  of  the  chin  on  the  sternum,  by  which  the 
anterior  fontanelle  is  so  elevated  that  its  rotation  backward  is  not  resisted 
by  the  inward  projection  of  the  left  ischial  spine,  and  the  occiput  is  cor- 
respondingly depressed.  If,  however,  this  flexion  is  not  complete,  and 
the  anterior  fontanelle  is  so  low  as  to  be  readily  within  reach  of  the  fin- 
ger, considerable  difliculty  is  likely  to  be  experienced.  In  many  such 
cases  rotation  is  still  eventually  eflected,  but  in  others  it  is  not ;  and  the 
labor  is  then  terminated  with  the  face  to  the  pubes,  but  at  the  ex- 
pense of  considerable  delay  and  difficulty.  According  to  Dr.  Uvedale 
West  of  Alford,  who  devoted  much  careful  study  to  the  subject,  this 
termination  occurs  in  about  4  per  cent,  of  occipito-posterior  positions. 
When  it  is  about  to  happen  the  anterior  fontanelle  may  be  felt  very  low 
dowi),  and  sometimes  even  tlie  forehead  and  superciliary  ridges.  The 
uterine  force  pushes  down  the  occiput,  the  sinciput  being  fixed  behind 
the  pubes,  which  it  obviously  cannot  pass  under,  as  does  the  occiput  in 
the  fii-st  ptjsition.  Tlie  sinciput  therefore  becomes  more  flexed  and 
pushed  upward,  wliik;  the  r('sistaii('(;  of  the  ])e]vic  floor  directs  the  occi- 
put f(>rward.  'J'h(!  |)(,TiiH!Uiii  now  Ix'comes  enormously  distended  l)y  the 
back  part  of  the  head,  and  is  in  great  dang(!r  of  laceration.  The  occi- 
put is  eventually,  but  not  without  nmch  difliculty,  expelled.     A  process 


278  LABOR. 

of  extension  now  occurs,  the  nape  of  the  neck  being  fixed,  as  it  were, 
against  the  centre  of  the  perineum,  the  expelling  force  now  acting  on  the 
forehead  and  producing  rotation  of  the  head  on  its  transverse  axis.  The 
forehead  and  face  are  thus  protruded,  and  the  body  follows  without 
difficulty. 

It  is  said  that  in  a  few  exceptional  cases,  where  the  anterior  fontanelle 
is  much  depressed,  the  labor  may  terminate  by  the  conversion  of  the  pres- 
entation into  one  of  the  face,  the  head  rotating  on  its  transverse  axis, 
the  forehead  passing  to  the  posterior  part  of  the  pelvis,  and  the  chin 
emerging  under  the  perineum.  It  is  obvious,  however,  that  this  change 
can  only  occur  when  the  head  is  unusually  small,  and  it  must  of  neces- 
sity be  extremely  rare. 

Relative  Frequency  of  Second  and  Third  Positions. — Reference  has 
already  been  made  to  Naegele's  views  as  to  the  rarity  of  the  second  posi- 
tion, and  to  his  opinion  that  cases  in  which  the  occiput  was  found  to 
point  to  the  right  foramen  ovale  were  only  transitional  stages  in  the 
rotation  of  occipito-posterior  positions.  Such  an  assumption,  however, 
is  unwarrantable  unless  the  case  has  been  watched  from  the  very  com- 
mencement of  labor.  Many  perfectly-qualified  observers  have  arrived 
at  the  conclusion  that  second  positions  are  far  more  common  than  Nae- 
gele  supposed  ;  and  in  the  table  already  quoted  it  will  be  seen  that  while 
Murphy  estimates  the  second  and  third  as  being  equally  fi^equent,  Swayne 
believes  the  second  to  be  much  more  common  than  the  third.  It  is 
probable  that  the  weight  of  Naegele's  authority  has  induced  many 
observers  to  classify  second  positions  as  third  positions  in  which  partial 
rotation  has  already  been  accomj)lished.  My  own  experience  would  cer- 
tainly lead  me  to  think  that  second  positions  are  very  far  from  uncom- 
mon.    The  question,  however,  must  be  considered  to  be  in  abeyance 

Fig.  104. 


Fourth  Position  of  Occiput  at  Telvic  Brim. 

until  further  observations  by  competent  authorities  enable  us  to  decide 
conclusively. 

Fourth,  or  Left  Occipito-sacro-iliac. — The  fourth  position  is  just  as 
much  the  reverse  of  the  second  as  the  third  is  of  the  first.  The  occiput 
points  to  the  left  (Fig.  104)  sacro-iliac  synchondrosis,  and  the  finger  im- 
pinges on  the  right  parietal  bone.  The  mechanism  is  precisely  the  same 
as  in  the  third  position,  the  rotation  taking  place  from  left  to  right. 


DELIVERY  IN  HEAD  PRESENTATIONS.  279 

Formation  of  the  Caput  Succedaneiim. — The  formation  of  the  caput 
succedaneum  has  been  ah^eady  alhided  to.  This  term  is  applied  to  the 
oedematous  swelling  which  forms  on  the  head,  and  is  produced  by  effusion 
from  the  obstruction  of  the  venous  circulation  caused  by  the  pressure  to 
■svhich  the  head  is  subjected.  It  follows  that  the  size  of  the  swelling  is 
in  direct  proportion  to  the  length*  of  the  labor.  In  rapid  deliveries,  in 
which  the  head  is  forced  through  the  pelvis  quickly,  it  is  scarcely,  if  at 
all,  developed,  while  after  j^rotracted  labors  it  is  large  and  distinct,  and 
may  obscure  the  diagnosis  of  the  position  by  preventing  the  sutures  and 
fontanelles  being  felt.  Its  situation  varies  according  to  the  position  of 
the  head  ;  thus,  in  the  first  and  fourth  positions  it  forms  on  the  right 
parietal  bone,  in  the  second  and  third  on  the  left ;  and  we  may  therefore 
verify,  by  inspection  of  its  site,  the  accuracy  of  our  diagnosis. 

An  ordinary  mistake  which  has  been  made  by  obstetricians  is  to  regard 
the  caput  succedaneum  as  formed  at  the  point  where  the  head  has  been 
most  subjected  to  pressure ;  while,  in  fact,  it  forms  on  that  part  which 
is  most  unsupported  by  the  maternal  structures,  and  where  the  swelling 
may  consequently  most  readily  occur.  Therefore,  in  the  early  stages  of 
the  labor  it  always  forms  on  the  part  of  the  head  which  lies  in  the  circle 
of  the  OS  uteri ;  while  in  subsequent  stages  it  forms  on  that  which  lies 
in  the  axis  of  the  v^aginal  canal,  and  eventually  is  most  prominent  on 
the  Ytart  that  is  first  expelled  from  the  vulva. 

Alteration  in  the.  Shape  of  the  Head  from  Ilouldinq. — A  few  words 
may  be  said  as  to  the  alteration  in  the  form  of  the  foetal  head  which 
occurs  in  tedious  labors,  and  results  from  the  moulding  which  it  has 
undergone  in  its  passage  through  the  pelvis.  The  smaller  the  pelvis  and 
the  greater  the  pressure  applied  to  the  head  during  delivery,  the  more 
marked  this  is.  The  result  is,  that  in  vertex  presentations  the  occipito- 
mental and  occipito-frontal  diameters  are  elongated  to  the  extent  of  an 
inch  or  even  more,  while  the  transverse  diameters  are  lessened,  from 
compression  of  the  parietal  bones.  This  moulding  is  of  unquestionable 
value  in  facilitating  the  birth  of  the  child.  The  amount  of  apparent 
deformity  is  very  considerable,  and  may  even  give  rise  to  some  anxiety. 
It  is  well  to  remember,  therefore,  that  it  is  always  transient,  and  that  in 
a  few  hours,  or  days  at  most,  the  elasticity  of  the  soft  cranial  bones 
causes  them  to  resume  their  natural  form.  The  caput  succedaneum  also 
disappears  rapidly ;  therefore,  no  amount  of  deformity  from  either  of 
these  causes  need  give  rise  to  anxiety  or  call  for  any  treatment. 


i 


280  LABOR. 


CHAPTER    III. 

MANAGEMENT  OF  NATUKAL  LABOR. 

Although  labor  is  a  strictly  physiological  function,  and  in  a  large 
majority  of  cases  might,  no  doubt,  be  safely  accomplished  without 
assistance  from  the  accoucheur,  still,  medical  aid,  properly  given,  is 
ahvays  of  value  in  facilitating  the  process,  and  is  often  absolutely  essen- 
tial for  the  safety  of  the  mother  and  child. 

Preparatory  Treatment. — The  management  of  the  pregnant  M'oman 
before  delivery  is  a  point  which  should  always  receive  the  attention  of 
the  medical  attendant,  since  it  is  of  consequence  that  the  labor  should 
come  on  when  she  is  in  as  good  a  state  of  health  as  possible.  For  this 
purpose  ordinary  hygienic  precautions  should  never  be  neglected  in  the 
latter  months  of  gestation.  The  patient  should  take  regular  and  gentle 
exercise,  short  of  fatigue,  and,  if  the  weather  permit,  should  sjjend  as 
much  of  her  time  as  possible  in  the  open  air.  Hot  rooms,  late  hours, 
and  excitement  of  all  kinds  should  be  strictly  avoided.  The  diet  should 
be  simple,  nutritious,  and  unstimulating.  The  state  of  the  bowels 
should  be  particularly  attended  to.  During  the  few  days  preceding 
labor  the  descent  of  the  uterus  often  causes  pressure  on  the  rectum  and 
prevents  its  evacuation.  Hence  it  is  customary  to  prescribe  occasional 
gentle  aperients,  such  as  small  doses  of  castor  oil,  for  a  few  days  before 
the  expected  period  of  delivery.  Some  caution,  however,  is  necessary, 
as  it  is  certainly  not  very  uncommon  for  labor  to  be  determined  rather 
sooner  than  was  anticipated  in  consequence  of  the  irritation  of  too  large 
a  purgative  dose.  The  state  of  the  bo^A•els  should  always  be  inquired 
into  at  the  commencement  of  labor,  and  if  there  be  any  reason  to  sus- 
pect that  they  are  loaded  a  copious  enema  should  be  administered.  This 
is  ahvays  a  proper  precaution  to  take,  for  a  loaded  rectum  is  a  common 
cause  of  irregular  and  ineffective  uterine  action ;  and  even  when  it  does 
not  produce  this  result,  the  escape  of  the  feces,  in  consequence  of  pres- 
sure on  the  bowel  during  the  propulsive  stage,  is  always  disagreeable 
both  to  the  patient  and  practitioner. 

Dre.s'.S'  of  Patient  during  Pregnancy. — The  dress  of  the  patient  during 
pregnancy  may  be  here  adverted  to,  for  much  discomfort  may  arise,  and 
the  satisfactory  progress  of  labor  may  even  be  interfered  ^vith,  from 
errors  in  this  respect. 

After  the  uterus  has  risen  out  of  the  pelvis  the  ordinary  corset  which 
most  women  wear  is  apt  to  produce  very  injurious  pressure ;  still  more 
so  when  attempts  are  made  to  conceal  the  increased  size  by  tight-lacing. 
After  the  fourth  or  fifth  month,  therefore,  the  comfort  of  the  patient  is 
much  increased  by  wearing  a  specially-constructed  pair  of  stays  with 
elastic  let  into  the  sides  and  front,  so  that  they  accommodate  themselves 
to  the  gradual  increase  of  the  figure.  Such  are  made  by  all  stay-makers, 
and  should  be  worn  whenever  the  circumstances  of  the  patient  permit. 


MANAGEMENT  OF  NATURAL  LABOR.  281 

Failing  this,  it  is  better  to  avoid  the  use  of  the  corset  altogether,  and  to 
have  as  little  pressure  on  the  uterus  as  possible,  although  many  women 
cannot  do  without  the  support  to  which  they  are  accustomed.  To  mul- 
tipar?e,  especially  if  there  be  much  laxity  of  the  abdominal  parietes,  a 
well-fitting  elastic  abdominal  belt  is  often  a  great  comfort.  This  is  con- 
structed so  that  it  can  be  tightened  when  the  patient  is  walking  and  in 
the  erect  position,  when  such  support  is  most  required,  and  readily 
loosened  when  desired. 

Necessity  of  Attending  to  the  First  Summons. — It  is  hardly  necessary 
to  insist  on  the  necessity  of  the  practitioner  attending  immediately  to 
the  first  summons  to  the  patient.  It  is  true  that  he  may  very  often  be 
sent  for  long  before  he  is  actually  required.  But,  on  the  other  hand,  it 
is  qtiite  impossible  to  foresee  what  may  be  the  state  of  any  individual 
case.  By  prompt  attention  he  may  be  able  to  rectify  a  malposition  or 
prevent  some  impending  catastrophe,  and  thus  save  his  patient  from 
consequences  of  the  utmost  gravity. 

Articles  to  be  Taken  by  the  Accoucheur. — The  practitioner  should 
always  be  provided  with  the  articles  which  he  may  require.  The 
ordinary  obstetric  cases,  containing  one  or  two  bottles .  and  a  catheter, 
such  as  are  sold  by  most  instrument-makers,  are  cumbrous  and  useless, 
while  "  obstetric  bags"  are  expensive  luxuries  not  within  the  reach  of 
all.  Every  one  can  manufacture  an  excellent  obstetric  bag  for  himself, 
at  a  small  expense,  by  having  compartments  for  holding  bottles  stitched 
on  to  the  sides  of  an  ordinary  leather  bag,  such  as  is  sold  for  a  few 
shillings  at  any  portmanteau-maker's.  It  is  a  great  comfort  to  have  at 
hand  all  that  may  be  required,  and  the  bag  should  contain  chloroform 
or  other  ansesthetic,  chloral,  laudanum,  the  liquor  ferri  perchloridi  of 
the  Pharmacopoeia,  the  liquid  extract  of  ergot,  and  a  hypodermic 
syringe,  with  bottles  containing  ether  and  a  solution  of  ergotin  for 
subcutaneous  injection.  If  it  also  contain  a  Higginson's  syringe,  a 
small  elastic  catheter,  a  good  pair  of  forceps,  and  one  or  two  suture- 
needles,  with  some  silver  wire  or  carbolized  catgut,  the  practitioner  is 
provided  against  any  ordinary  contingency.  Other  articles  that  may  be 
required,  such  as  thread,  scissors,  and  the  like,  are  generally  provided 
by  the  nurse  or  patient. 

Duties  on  First  Visiting  the  Patient. — On  arriving  at  the  house  the 
practitioner  should  have  his  visit  announced  to  the  patient ;  and  he 
will  very  often  find  that  the  first  effect  of  his  presence  is  to  arrest 
the  pains  that  have  been  hitherto  progressing  rapidly,  thereby  afford- 
ing a  very  conclusive  proof  of  the  influence  of  mental  impressions 
on  the  progress  of  labor.  If  the  pains  be  not  already  propulsive,  it  is 
well  tliat  he  should  occupy  himself  at  first  in  general  inquiries  from  the 
attendants  as  to  the  progress  of  the  labor,  and  in  seeing  that  all  the 
ne(x;ssary  arrangements  are  satisfactorily  carried  out,  so  as  to  allo^v  the 
patient  time  to  get  accustomed  to  his  presence.  If  he  have  any  choice 
in  the  matter,  he  should  endeavor  to  secure  a  large,  airy,  and  well- 
ventilated  apartment  for  the  lying-in  room,  as  far  removed  as  possible 
from  without.  He  may  also  see  to  the  IkmI,  whicih  should  be  without 
cuKains  and  prepared  for  tlu;  labor  by  having  a  water-proof  sheeting 
laid  under  a  folded  blanket  or  sheet,  on  which  the  natient  lies.     These 


282 


LABOR. 


receive  the  discharges  during  labor,  and  can  be  pulled  from  under  the 
patient  after  delivery,  so  as  to  leave  the  dry  clothes  beneath.  Among 
the  k)wer  classes  the  lying-in  chamber  is  considered  a  legitimate  meeting- 
place  for  numerous  female  friends  to  gossip,  whose  conversation  is  often 
distressing,  and  is  certainly  injurious,  to  a  woman  in  the  excitable  con- 
dition associated  with  labor.  The  medical  attendant  should  therefore 
insist  on  as  much  quiet  as  possible,  and  should  allow  no  one  in  the  room 
except  the  nurse  and  some  one  friend  whose  presence  the  patient  may 
desire.  The  husband's  presence  must  be  left  to  the  wishes  of  the  patient. 
Some  women  like  their  husbands  to  be  with  them,  while  others  prefer  to 
be  without  them,  and  the  medical  attendant  is  bound  to  act  in  accord- 
ance with  the  patient's  desire. 

Vaginal  Examination. — If  pains  be  actually  present,  a  vaginal  exam- 
ination is  essential,  and  should  not  be  delayed.  It  enables  us  to  ascertain 
whether  the  labor  has  commenced  or  not,  and  whether  the  presentation 
is  natural  or  otherwise.  The  pains,  although  apparently  severe,  may  be 
altogether  sjDurious,  and  labor  may  not  have  actually  commenced.  It 
is  of  much  importance,  for  both  our  own  credit  and  comfort,  that  we 
should  be  able  to  diagnose  the  true  character  of  the  pains ;  for  if  they 
be  so-called  "  false"  pains,  we  might  wait  hours  in  fruitless  expectation 

Fig.  105. 


Examination  during  the  First  Stage. 

of  progress,  while  delivery  is  still  far  off.  The  necessity  of  ascertaining, 
therefore,  the  actual  state  of  affairs  need  not  further  be  insisted  on. 
j  Character  of  False  Fains. — Fake  pains  are  chiefly  characterized  by 
their  irregularity,  sometimes  coming  on  at  short  intervals,  sometimes 
[with  many  hours  between  them  ;  they  also  vary  much  in  intensity,  some 
I  being  very  sharp  and  painful,  while  others  are  slight  and  transient.  In 
these  respects  they  differ  from  the  true  pains  of  the  first  stage,  which  are 


MANAGEMENT  OF  NATURAL  LABOR.  283 

at  first  slight  and  short,  and  gradually  recur  with  increased  force  and 
regularity.  The  situation  of  the  two  kinds  of  pains  also  varies,  the  false 
pains  being  chiefly  situated  in  front,  while  the  true  pains  are  felt  most  in 
the  back  and  gradually  shoot  round  toward  the  abdomen.  Nothing 
short  of  a  vaginal  examination  will  enable  us  to  clear  up  the  diagnosis 
satisfactorily.  If  the  labor  have  actually  commenced,  the  os  will  be  i 
more  or  less  dilated  and  its  edges  thinned,  while  with  each  pain  the  [ 
cervix  will  become  rigid  and  the  membranes  tense  and  prominent.  The  ; 
false  pains,  on  the  contrary,  have  no  effect  on  the  cervix,  which  remains 
flaccid  and  undilated,  or,  if  the  os  be  sufficiently  open  to  admit  the  tip 
of  the  finger,  the  membranes  will  not  become  prominent  during  the  con- 
traction. Under  such  circumstances  we  may  confidently  assure  the  pa- 
tient that  the  pains  are  false,  and  measures  should  be  taken  to  remove 
the  irritation  which  produces  them.  In  the  large  majority  of  cases  the 
cause  of  the  spurious  pains  will  be  found  to  be  some  disordered  state 
of  the  intestinal  tract ;  and  they  will  be  best  remedied  by  a  gentle 
aperient — such  as  castor  oil  or  the  compound  colocynth  pill  with  hyos- 
cyamus — followed  by,  or  combined  with,  a  sedative,  such  as  twenty 
minims  of  laudanum  or  chlorodyne.  Shortly  after  this  has  been  admin- 
istered the  false  pains  will  die  away,  and  not  recur  until  true  labor 
commences. 

Mode  of  Conducting  a  Vaginal  Examination. — For  a  vaginal  exam- 
ination the  patient  is  placed  by  the  nurse  on  her  left  side,  close  to  the .,, 
edge  of  the  bed,  with  the  legs  flexed  on  the  abdomen.    The  practitioner,  '^' 
being  seated  by  the  edge  of  the  bed,  passes  the  index  finger  of  the  right 
hand,  previously  lubricated  with  carbolized  oil  or  cold  cream,  up  to  the 
vulva,  and  gently  insinuates  it  into  the  orifice  of  the  vagina,  then  pushes 
it  backward  in  the  axis  of  the  vaginal  outlet,  and  finally  turns  it  upward 
and  forward  so  as  to  more  readily  reach  the  cervix.     This  it  may  not 
always  be  easy  to  do,  for  at  the  commencement  of  labor  the  cervix  may 
be  so  high  as  to  be  reached  with  difficulty,  or  it  may  be  directed  back- 
ward so  as  to  point  toward  the  cavity  of  the  sacrum.     The  exploration 
is  often  much  facilitated  by  depressing  the  uterus  from  without  by  the 
left  hand  placed  on  the  abdomen.     Our  object  is  not  only  to  ascertain     : 
the  state  of  the  cervix  as  to  softness  and  dilatation,  but  also  the  presen-  1 
tation,  the  condition  of  the  vagina,  and  the  capacity  of  the  pelvis.     The 
examination  is  generally  commenced  during  a  pain,  at  which  time  it  is     Ji 
less  depressing  to  the  patient ;  but  in  order  to  be  satisfactory  the  finger     '^^ 
must  remain  in  the  vagina  until  the  pain  is  over,  the  examination  being  : 
concluded  in  the  interval  between  this  pain  and  the  next. 

In  head  presentations  the  round  mass  of  the  cranium  is  generally  at 
once  felt  thi'ough  the  lower  part  of  the  uterus,  and  then  we  have  the  sat- 
isfaction oi'  being  al>le  to  assure  the  patient  that  all  is  right.  If  the  os 
be  sufficiently  dilated,  we  can  also  feel  through  it  the  occiput  covei;ed  by 
the  membranes.  It  is  impossible  at  this  time  to  make  out  the  exact  posi- 
tion of  the  head  by  means  of  the  sutures  and  fontanel les,  which  are  too 
higli  up  to  be  within  reach.  Nor  should  any  attempt  be  made  to  do  so,  I 
for  fear  of  prematunvly  ru])turing  the  membranes.  The  flu^t  that  the  \ 
head  is  presenting  is  all  that  wa  n'(|iiii-('  to  know  at  tiiis  stage  of  tlu;  labor.  ; 

The  (Jondltlon  of  the  O.s  an  Ivdi eating  the  Progress  of  Labor. — The 


284  LABOR. 

condition  of  the  os  itself,  as  to  rigidity  and  dilatation,  -will  materially 
assist  ns  in  forming  an  opinion  as  to  the  progress  and  probable  duration 
of  the  labor ;  but,  although  the  friends  will  certainly  press  for  an  opin- 
ion on  this  point,  the  cautious  practitioner  will  be  careful  not  to  commit 
himself  to  a  positive  statement,  which  may  so  easily  be  falsified.  It  will 
suffice  to  assure  the  friends  that  everything  is  satisfactory,  but  that  it  is 
impossible  to  say  with  any  certainty  how  rapidly,  or  the  reverse,  the  case 
may  progress. 

If  the  pains  be  not  very  frequent  or  strong,  and  the  os  not  dilated  to 
more  than  the  size  of  a  shilling,  a  considerable  delay  may  be  anticipated, 
and  the  presence  of  the  medical  attendant  is  useless.  He  may,  therefore, 
safely  leave  the  patient  for  an  hour  or  more,  provided  he  be  within  easy 
reach.  It  is  needless  to  say  that  this  should  never  be  done  unless  the 
exact  presentation  be  made  out.  If  some  part  other  than  the  head  be 
presenting,  it  will  probably  be  impossible  to  make  it  out  until  dilatation 
has  progressed  further ;  and  the  practitioner  must  be  incessantl}^  on  the 
watch  until  the  nature  of  the  case  be  made  out,  so  as  to  be  able  to  seize 
the  most  favorable  moment  for  interference,  should  that  be  necessary. 
-  Position  of  Patient  during  First  Stage. — The  position  of  the  patient 

"^       is  a  matter  of  some  moment  in  the  first  stage.    It  is  a  decided  advantage 
'     that  she  should  not  be  then  in  a  recumbent  position  on  her  side,  as  is 
usual  in  the  second  stage ;  for  it  is  of  importance  that  the  expulsive  force 
should  act  in  such  a  way  as  to  favor  the  descent  of  the  head  into  the  pel- 
vis— i.  e.  perpendicularly  to  the  plane  of  its  brim — and  also  that  the 
w^eight  of  the  child  should  operate  in  the  same  way.     Therefore,  the 
ordinary  custom  of  allowing  the  patient  to  walk  about  or  to  recline  in 
a  chair  is  decidedly  advantageous ;  and  it  wall  often  be  observed  that 
the  pains  are  more  lingering  and  ineffective  if  she  lie  in-  bed.     If  the 
patient  be  a  multipara,  or  if  the  abdomen  be  someM'hat  pendulous,  an 
^.     I  abdominal  bandage,  by  supporting  the  uterus,  will  greatly  favor  the 
I  progress  of  this  stage.     Keeping  the  patient  out  of  bed  has  the  further 
'\  (mI  .  1  advantage  of  preventing  her  being  unduly  anxious  for  the  termination 
6fi/»w^!of  the  labor;  and  a  little  cheerful  conversation  will  keep  up  her  spirits 
and  obviate  the  mental  depression  which  is  so  common.     Good  beef-tea 
may  be  freely  administered,  W'ith  a  little  brandy  and  water  occasionally 
if  the  patient  be  weak,  and  will  be  useful  in  supporting  her  strength. 

Vaginal  Examinations. — Over-frequent  vaginal  examinations  at  this 
period  should  be  avoided,  for  they  serve  no  useful  purpose  and  are  apt  to 
irritate  the  cervix.  It  will  be  necessary,  however,  to  ascertain  the  prog- 
ress of  the  dilatation  at  intervals. 

Artificial  Rupture  of  the  Membranes. — When  once  the  os  is  fully  dila- 
ted, the  membranes  may  be  artificially  ruptured  if  they  have  not  broken 
spontaneously,  for  they  no  longer  serve  any  useful  purpose,  and  only 
retard  the  advent  of  the  propulsive  stage.     This  can  be  easily  done  by 
pressing  on  them,  when  they  are  rendered  tense  during  a  pain,  by  some 
pointed  instrument,  such  as  the  end  of  a  hairpin,  which  is  always  at 
[  hand.     In  some  cases,  indeed,  it  is  even  expedient  to  rupture  the  mem- 
branes before  the  os  is  fully  dilated.    Thus,  it  not  unfrequently  happens, 
I  when  the  amount  of  liquor  amnii  is  at  all  excessive,  that  the  os  dilates 
■  to  the  size  of  a  five-shilling  piece  or  more ;  but,  although  it  is  perfectly 


MANAGEMENT  OF  NATURAL  LABOR.  285 

soft  and  flaccid,  it  opens  up  no  farther  until  the  liquor  amnii  is  evacu- 
ated, when  the  propulsive  pains  rapidly  complete  its  dilatation.  Some 
experience  and  judgment  is  required  in  the  detection  of  such  cases, 
for  if  we  evacuate  the  liquor  amnii  prematurely  the  pressure  of  the 
head  on  the  cervix  may  produce  irritation  and  seriously  prolong  the 
labor.  This  manoeuvre  is  most  likely  to  be  useful  when  the  pains  are 
strong  and  the  os  perfectly  flaccid,  and  when  the  membranes  do  not 
protrude  through  the  os  and  eifect  further  dilatation. 

It  is  sometimes  not  easy  to  ascertain  whether  the  membranes  are  rup- 
tured or  not.  This  is  most  likely  to  be  the  case  when  the  head  is  low  j 
down  and  the  amount  of  liquor  amnii  is  so  small  that  the  pouch  does 
not  become  prominent  during  the  pains.  A  little  care,  however,  will  I 
enable  us,  if  the  membranes  be  ruptured,  to  feel  the  rugosities  of  the 
scalj)  covered  with  hair,  and  to  distinguish  it  from  the  smooth  polished 
surface  of  the  membranes. 

Treatment  of  the  Propukive  Stage. — After  the  evacuation  of  the  liquor  "^j:.  »^ 
amnii  there  is  generally  a  lull  in  the  progress  of  the  labor,  the  pains,     ^'  ■-' 
however,  soon  recurring  with  increased  force  and  frequency,  and  propel- 
ling the  head  through  the  pelvic  cavity.     The  change  in  the  character 
of  the  j)ains  is  soon  appreciated  by  the  bearing-down  efforts  by  which 
they  are  accompanied,  as  well  as  by  .their  increased  length  and  intensity. 

Position  of  the  Patient  during  the  Second  Stage. — It  is  now  advisable  p  r 
that  the  patient  be  placed  in  bed ;  and  in  this  country  it  is  usual  for  her 
to  lie  on  her  left  side,  with  her  nates  parallel  to  the  edge  of  the  bed  and  '  ''^ 
her  body  lying  across  it.  This  is  the  established  obstetric  position  in 
England,  and  it  would  be  useless  to  attempt  to  insist  on  any  other,  even 
if  it  were  advisable.  Although  the  dorsal  position  is  preferred  on  the 
Continent,  it  is  difficult  to  see  wherein  its  advantages  consist.  It  cer- 
tainly leads  to  unnecessary  exposure  of  the  person,  and  it  is,  on  the  M^hole, 
less  easy  to  reach  the  patient,  so  placed,  for  the  necessary  manipulations. 
Moreover,  the  dorsal  position  increases  the  risk  of  laceration  of  the  per- 
ineum, by  bringing  the  weight  of  the  child's  head  to  bear  more  directly 
upon  it.  Thus,  Schroeder  found  that  lacerations  occurred  in  37.6  per 
cent,  of  cases  delivered  on  the  back,  as  against  24.4  per  cent,  in  other 
positions. 

The  patient  usually  remains  in  bed  during  the  whole  of  this  stage, 
and  it  is  customary  for  the  nurse  to  tie  to  the  foot  of  the  bed  a  jack- 
towel,  which  is  laid  hold  of  and  used  as  a  support  in  making  bearing- 
down  elforts.  If  the  pains  be  few  and  far  between,  and  the  patient  fincls 
it  more  comfortable  to  get  up  occasionally,  there  is  no  reason  why  she 
should  not  do  so.  On  the  contrary,  as  we  shall  subsequently  see  in  treat- 
ing of  lingering  labor,  the  pains  under  such  circumstances  are  often 
increased  in  the  sitting  posture,  in  consequence  of  the  weight  of  the  child 
producing  increased  pressure  on  the  nerves  of  the  vagina. 

Detection  of  the  Podtion  of  Head. — At  tins  time  vaginal  examination,  1 
which  should  be  more  frequently  repeated  tluui  in  the  fli-st  stage,  enables 
us  to  ascertain  precisely  the  ])osition  of  the  head  by  means  of  the  sutures  I 
and  fontanelles,  as  well  as  to  watch  its  pi'ogress. 

Management  of  the  Anterior  TJ,p  of  Cervix  lohen  Impacted  between  the 
Head  find  Pelvis. — It  not  unfreqncntly  h;i]ipens  that  the  head  descends 


286  LABOR. 

into  the  pelvis,  even  to  its  floor,  without  the  os  having  entirely  disap- 
peared. The  anterior  lip  especially  is  apt  to  get  caught  between  the 
head  and  pubes,  to  become  swollen  by  the  pressure  to  which  it  is  sub- 
jected, and  then  to  retard  the  progress  of  the  labor.  There  can  be  no 
reasonable  objection  to  attempting  to  prevent  this  cause  of  delay  by 
pressing  on  the  incarcerated  lip  during  the  interval  of  the  pains,  so  as 
to  push  it  above  the  head,  and  maintain  it  there  during  the  pains  until 
the  head  descends  below  it.  This  manoeuvre,  if  done  judiciously  and 
^vithout  any  undue  roughness  or  force,  is  certainly  not  liable  to  be 
attended  by  any  of  the  evil  consequences  w^hich  many  obstetricians  have 
attributed  to  it :  it  is,  indeed,  a  matter  of  common  sense  that  the  injury 
to  the  cervix  is  likely  to  be  less  if  it  be  pushed  gently  out  of  the  way 
than  if  it  be  left  to  be  tightly  jammed  for  hours  between  the  presenting 
part  and  the  bony  pelvis.  This  mode  of  assistance  is  very  different  from 
the  digital  dilatation  of  a  rigid  cervix,  which  was  formerly  much  prac- 
tised, especially  in  Edinburgh,  in  consequence  of  the  recommendation  of 
Hamilton,  and  which  was  properly  objected  to  by  the  great  majority  of 
obstetricians. 

If  the  pains  be  producing  satisfactory  progress,  no  further  interference 
is  required.  The  medical  attendant  should,  however,  see  that  the  blad- 
der is  evacuated  ;  and  if  it  have  not  been  so  for  some  hours,  it  may  be 
necessary  to  draw  off  the  urine  by  the  catheter.  Whenever  the  labor  is 
lengthy  he  should  occasionally  practise  auscultation,  so  as  to  satisfy  him- 
self that  the  foetal  circulation  is  being  satisfactorily  carried  on. 

Begukdion  of  the  Voluntary  Bearing-doum  Efforts. — The  regulation 
of  the  bearing-down  efforts  at  this  time  is  of  importance.  It  is  common 
for  the  nurse  "to  urge  the  patient  to  help  herself  by  straining ;  and  it  is 
certain  that  by  voluntary  action  of  this  kind  she  can  materially  increase 
the  action  of  the  accessory  muscles  of  parturition.  If  the  pains  be 
strong  and  the  labor  promise  to  be  rapid,  such  voluntary  exertions  are 
not  likely  to  be  prejudicial.  On  the  other  hand,  if  the  case  be  progress- 
ing slowly  they  only  unnecessarily  fatigue  the  patient,  and  should  be 
discouraged.  When  the  perineum  is  distended  we  may  even  find  it 
advisable  to  urge  the  patient  to  cease  all  voluntary  effort,  and  to  cry  out, 
for  the  express  purpose  of  lessening  the  tension  to  which  the  perineum 
is  subjected.  This  is  the  stage  in  which  anaesthesia  is  most  serviceable, 
but  its  employment  must  be  separately  discussed. 

Distension  of  the  Berineum. — As  the  head  descends  more  and  more 
the  perineum  becomes  distended,  and  there  is  considerable  difference  of 
opinion  amongst  accoucheurs  as  to  the  management  of  the  case  at  this 
time.  In  most  obstetric  works  the  practitioner  is  advised  to  endeavor  to 
prevent  laceration  by  the  manoeuvre  that  is  described  as  "  supporting  the 
perineum."  By  this  is  meant,  laying  the  palm  of  the  hand  on  the  dis- 
tended structures  and  pressing  firmly  upon  them  during  the  acme  of  the 
pain,  with  the  view  of  mechanically  preventing  their  tearing.  There 
can  be  little  doubt  that  this,  or  some  modification  of  it,  is  the  practice 
now  followed  by  the  large  majority  of  practitioners.  Of  late  years  the 
evil  effects  likely  to  follow  it  have  been  specially  dwelt  upon  by  Graily 
Hewitt,  Leishman,  Goodell,  and  other  writers,  who  maintain  that  by 
pressure  exerted  in  this  fashion  we  not  only  fail  to  prevent,  but  actually 


MANAGEMENT  OF  NATURAL  LABOR. 


287 


favor,  laceration,  in  consequence  of  the  pressure  producing  increased  ute- 
rine action  just  at  the  time  when  forcible  distension  of  the  perineum  is 
likely  to  be  hurtful.  Therefore,  some  hold  that  the  perineum  ought  to 
be  left  entirely  alone,  and  that  the  head  should  be  allowed  gradually  to 
distend  it,  without  any  assistance  on  the  part-  of  the  practitioner. 

Much  error  may  be  traced  to  a  misconception  of  what  is  required. 
The  term  "  supporting  the  perineum  "  conveys  an  unquestionably  errone- 
ous idea,  and  it  is  certain  that  no  one  can  prevent  laceration  by  mechani- 
cal support.  If  the  term  "  relaxation  of  the  perineum  "  was  employed, 
we  should  have  a  far  more  accurate  idea  of  what  should  be  aimed  at, 
and  if  this  be  borne  in  mind  I  think  it  cannot  be  questioned  that  nature 
may  be  most  usefully  assisted  at  this  stage. 

Dr.  GoodeU's  Method. — Dr.  Goodell  of  Philadelphia  has  specially 
studied  this  subject,  and  has  recommended  a  method  the  object  of  ^viiich 
is  to  relax  the  perineum.  His  advice  is,  that  one  or  two  fingers  of  the 
left  hand  should  be  inserted  into  the  rectum,  by  which  the  perineum 
should  be  hooked  up  and  pulled  forward  over  the  head,  toward  the 
pubes,  the  thumb  of  the  same  hand  being  placed  on  the  advancing  head,  so 
as  to  restrain  its  progress  if  needful.  I  have  adopted  this  plan  frequently, 
and  believe  that  it  admirably  answers  its  purpose,  especially  when  the 
perineum  is  greatly  distended  and  laceration  is  threatened.  It  must  be 
admitted  that  the  insertion  of  the  fingers  into  the  anal  orifice,  in  the 
manner  recommended,  is  repugnant  both  to  the  practitioner  and  patient, 
and  the  same  result  can  be  obtained  in  a  less  unpleasant  way.  I  men- 
tion it,  however,  to  show  what  it  is  that  the  practitioner  must  aim  at. 
If,  when  the  head  is  distending  the  perineum  greatly,  the  thumb  and 
fore  finger  of  the  right  hand  are  placed  along  its  sides,  it  can  be  pushed 
gently  forward  over  the  head  at  the  height  of  the  pain,  while  the  tips  of 
the  fingers  may  at  the  same  time  press  upon  the  advancing  vertex,  so  as 
to  retard  its  progress  if  advisable  (Fig.  106).  By  this  means  the  sudden 
and  forcible  stretching  of  the  perineal  structures  is  prevented,  and  the 
chance  of  laceration  reduced  to  a  minimum,  while  nature's  mode  of 
relaxing  the  tissues,  by  dilatation  of  the  anal  orifice,  is  favored.  This 
is  very  different  from  the  mechanical  support  that  is  usually  recom- 
mended, and  the  less  pressure  that  is  applied  directly  to  the  perineum 
the  better.  Nor  is  it  either  needful  or  advisable  to  sit  by  the  patient 
with  the  hand  applied  to  the  perineum  for  hours,  as  is  so  often  practised. 
Time  should  be  given  for  the  gradual  distension  of  the  tissues  by  the 
alternate  advance  and  recession  of  the  head,  and  we  need  only  intervene 
to  assist  relaxation  when  the  stretching  has  reached  its  height  and  the 
head  is  about  to  be  expelled.  A  napkin  may  be  interposed  between  the 
hand  and  the  skin  for  tlic;  pur])ose  of  cleanliness.  Should  the  perineum 
be  excessively  tough  and  resistant,  assiduous  fomentation  with  a  hot 
sj)oiige  may  be  resorted  to,  and  will  be  of  some  service  in  promoting 
relaxation. 

Ineiaion  of  the  Perineum. — When  the  tension  is  so  great  that  lacera- 
tiou  seems  inevitable,  it  is  generally  recommended  that  a  slight  incision 
should  Ik;  made  on  eacli  side  of  tlu;  (-(iutral  raphe,  with  the  view  of  pre- 
venting spontaneous  lacei-ation.  This  may  no  doubt  be  done  with  ])er- 
fect  safijty,  but  I  (piesti(ju  if  it  is  likely  to  be  of  use.     The  idea  is  that 


288 


LABOR. 


an  incised  wound  is  likely  to  heal  more  readily  than  a  lacerated  one. 
When,  however,  a  distended  perineum  ruptures,  its  structures  are  so 
thinned  that  the  tear  is  always  linear,  and,  as  a  matter  of  fact,  the  edges 
of  the  tear  tire  always  as  clean  and  as  closely  in  apposition  as  if  the  cut 
had  been  made  with  a  knife.     Moreover,  the  laceration  invariably  heals 

Fig.  106. 


Mode  of  Effecting  Relaxation  of  the  Perineum. 

perfectly  if  only  the  edges  be  brought  into  contact  at  once  wath  one  or 
two  metallic  sutures.  I  believe,  therefore,  that  Goodell  is  right  in  stat- 
ing that  incision  of  the  perineum  is  rarely,  if  ever,  necessary,  unless  it 
is  hardened  by  previous  cicatrization.  In  almost  all  first  labors  the  four- 
chette  is  torn,  but  requires  no  treatment  of  any  kind.  In  some  cases, 
do  what  we  will,  more  or  less  laceration  occurs,  and  the  perineum  should 
always  be  examined  after  the  expulsion  of  the  child  to  see  if  any  tear 
has  taken  place. 

Treatment  of  Lacerations. — If  it  has  given  way  to  any  extent,  I 
believe  that  it  is  good  practice  to  insert  one  or  two  interrupted  sutures 
of  silver  wire  or  carbolized  gut  at  once.  Immediately  after  delivery  the 
sensibility  of  the  tissues  is  deadened  by  the  distension  to  which  they 
have  been  subjected,  and  the  sutures  can  be  inserted  with  little  or  no 
pain.  It  is  quite  true  that  lacerations  of  an  inch  or  less  will  generally 
heal  perfectly  well  of  themselves,  but  this  is  not  invariably  the  case, 
Avhile  healing  almost  certainly  follows  if  the  edges  be  brought  together 
at  once.  In  the  severer  forms  of  laceration,  extending  back  to,  or  even 
through,  the  sphincter,  the  precaution  is  all  the  more  necessary,  and  a 
subsequent  operation  of  gravity  may  in  this  way  be  avoided.  The 
sutures  can  be  removed  without  difficulty  in  a  week  or  so,  when  com- 
plete adhesion  has  taken  place. 

Kvpuhion  of  the  Chilrl. — The  head,  when  expelled,  should  be  received 
in  the  palm  of  the  right  hand,  while  the  left  hand  is  placed  upon  the 
abdomen  to  follow  down  the  uterus  as  it  contracts  and  expels  the  body. 


MANAGEMENT  OF  NATURAL  LABOR.  289 

There  is  generally  some  little  delay  after  the  expulsion  of  the  head,  and 
we  should  now  see  if  the  cord  surround  the  neck,  and  if  it  does  so  it  1 
should  be  drawn  over  the  head  ;  and,  if  this  is  not  possible,  it  may  be 
tied  and  divided  between  the  ligatures.     The  expulsion  of  the  body 
should  be  left  entirely  to  the  uterine  contractions.     If  there  be  undue 
delay,   we  may  endeavor  to  excite  uterine  action    by  friction  on  the 
fundus,  and  it  will  rarely  happen  that  sufficient  contraction  does  not 
now  come  on.     If  we  display  undue  haste  in  withdrawing  the  body,  we  l 
run  the  risk  of  emptying  the  uterus  while  its  tissues  are  relaxed,  and  so  I 
favor  hemorrhage.     If,  however,  there  seem  serious  danger  of  the  cliild  I 
being  asphyxiated,  its  expulsion  may  be  favored  by  gently  passing  the 
fore  finger  of  each  hand  within  the  axillae  and  using  traction ;  but  it  is 
only  very  exceptionally  that  such  interference  is  required. 

Promotion  of  Uterine  Contraction  after  the  Birth  of  the  Child. — As  j 
the  uterus  contracts  it  should  be  carefully  followed  down  through  the 
abdominal  parietes  by  the  left  hand,  which  should  grasp  it  as  the  body  ) 
is  expelled,  with  the  view  of  seeing  that  it  is  efficiently  contracted.  I 
This  is  a  point  of  vital  importance  in  preventing  hemorrhage,  which  ' 
will  presently  be  more  especially  considered. 

Ligature  of  the  Cord. — As  soon  as  the  child  cries  we  may  proceed  to 
tie  and  separate  the  cord.  For  this  purpose  the  nurse  usually  provides 
ligatures  composed  of  several  strands  of  whitey-brown  thread,  but  tape 
or  any  other  suitable  material  may  be  employed.  It  is  important, 
especially  if  the  cord  be  very  thick  and  gelatinous,  to  see  that  it  is  thor- 
oughly compressed,  so  that  the  vessels  are  obliterated,  otherwise  second- 
ary hemorrhage  might  occur.  The  cord  is  tied  about  an  inch  and  a 
half  from  the  child,  and  it  is  usual,  though  of  course  not  essential,  to 
place  a  second  ligature  about  two  inches  nearer  the  placental  extremity 
of  the  cord.  The  latter  is  perhaps  of  some  use  by  retaining  the  blood, 
and  thus  increasing  the  size  of  the  placenta  and  favoring  its  more  ready 
expulsion  by  uterine  contraction.  The  cord  is  then  divided  with  scis- 
sors between  the  ligatures,  the  child  wrapped  \\j>  in  flannel,  and  given 
to  the  nurse  or  a  bystander  to  hold,  while  the  attention  of  the  practi- 
tioner is  concentrated  on  the  mother  with  a  view  to  the  proper  man- 
agement of  the  third  stage  of  labor.  The  researches  of  Budin,'  Ribe- 
mont,^  and  others  show  that  there  is  a  distinct  advantage  in  not  tying 
the  cord  until  the  child  has  cried  lustily,  as  the  act  of  respiration 
tends  to  withdraw  the  placental  blood,  and  thus  increases  the  entire  I  ^^fU^. 
amount  of  blood  in  the  foetus.  It  is  said  that  after  late  ligature  of 
the  cord  the  child  is  more  vigorous  and  active  than  when  it  is  tied 
too  early. 

Treatment  of  the  Cord  hy  Laceration. — The  cord  may,  if  preferred,  be 
treated  with  perfect  safety  by  laceration.  This  method  was  first  brought 
under  my  notice  by  my  friend  Dr.  Stephen,  who  has  era})loyed  it  for 
many  years  and  in  several  hundred  cases.  The  cord  is  twisted  round 
the  index  fingers  of  both  hands  and  torn  through,  the  lacerated  vessels 
retracting  without  any  liemorrhage.  It  is  a  close  imitation  of  the 
method  instinctively  adopted  by  the  lower  animals,  who  gnaw  the  cord 
asunder,  and  lias  the;  advantage  of  dispensing  with  ligatures  altogether. 

'  Jjiidin,  Profjrcs  mcdicnle,  1870.  ''■  Arehiv.  de  Toxolog.,  Oct.,  1879. 

19 


290  LABOR. 

I  have  used  it  myself  in  a  large  number  of  cases,  but  prefer,  on  the 
whole,  the  plan  usually  adopted. 

Importance  of  Proper  Management  of  Third  Stage. — There  is  unques- 
tionably no  period  of  labor  where  skilled  management  is  more  important 
and  none  in  which  mistakes  are  more  frequently  made.  By  proper  care 
at  this  time  the  risk  of  post-partum  hemorrhage  is  reduced  to  a  min- 
imum, the  efficient  contraction  of  the  uterus  is  secured,  the  amount  and 
intensity  of  after-pains  are  lessened,  and  the  safety  and  comfort  of  the 
patient  greatly  promoted.  Moreover,  the  general  practice  as  to  the 
management  of  this  stage  is  opposed  to  the  natural  mechanism  of  pla- 
cental expulsion,  and  is  far  from  being  well  adapted  to  secure  the 
important  objects  which  we  ought  to  have  in  view.  Let  us  see  what  is 
the  practice  usually  recommended  and  followed,  and  then  we  shall  be  in 
a  position  to  understand  in  what  respects  it  is  erroneous.  For  this  pur- 
pose I  cannot  do  better  than  copy  the  directions  contained  in  one  of 
our  most  deservedly  popular  obstetric  text-books,  which  undoubtedly 
expresses  the  usual  practice  in  the  management  of  this  stage  :  "  When 
the  binder  is  applied  the  patient  may  be  allowed  to  rest  a  M'hile  if  there 
is  no  flooding ;  after  which,  ivhen  the  uterus  contracts,  gentle  traction 
may  be  made  by  the  funis  to  ascertain  if  the  placenta  be  detached.  If 
so,  and  especially  if  it  be  in  the  vagina,  it  may  be  removed  by  continu- 
ing the  traction  steadily  in  the  axis  of  the  upper  outlet  at  first,  at  the 
same  time  making  pressure  on  the  uterus."^ 

[In  this  country,  for  many  years,  the  uniform  teaching  has  been  that 
the  binder  should  not  be  aj)plied  until  the  uterus  has  expelled  the  pla- 
centa and  become  firmly  contracted.  Although  the  plan  of  expression 
was  not  carried  out  as  completely  as  is  now  taught  under  the  Cred6 
method,  that  of  stimulating  the  contractions  of  the  uterus  by  manipula- 
tion and  pressure  w^as  certainly  in  use  forty  years  ago.  When  the  size 
and  solidity  of  the  uterus,  as  ascertained  by  the  compressing  hand,  indi- 
cate that  the  placenta  has  been  expelled  into  the  vagina,  it  is  a  question 
whether  we  shall  cause  it  to  be  forced  through  the  vulva  by  pressing 
down  the  uterus  upon  it,  or  make  traction  upon  it  by  the  finger  hooking 
down  its  edge.  Occasionally,  we  find  a  patient  who  is  very  sensitive  to 
pressure  made  upon  her  uterus  after  it  has  become  firmly  contracted  ; 
and  in  such  a  case  it  may  be  well  to  depend  partly  upon  traction  for 
completing  the  delivery  of  the  secundines.  That  it  is  possible  for  the 
uterus  to  expel  the  placenta  suddenly  from  the  vagina  where  no  pressure 
has  been  made  is  evident  from  the  fact  that  a  physician  of  this  city,  who 
was  making  traction  upon  the  cord  under  the  old  method  some  years 
ago,  was  surprised  to  find  the  placenta  shoot  out  from  the  vulva  and 
dangle  by  the  funis  as  he  held  it  in  his  hand.  In  such  a  case  the  uterus 
must  have  been  aided  durino-  a  contraction  bv  voluntarv  abdominal 
pressure,  causing  the  os  to  descend  nearly  to  the  vulva.  It  is  very  evi- 
dent that  the  uterus  is  subject  to  muscular  fiitigue  and  to  the  exhaustion 
of  its  contractile  power  when  long  in  action ;  hence,  there  is  a  greater 
risk  of  uterine  atony  and  hemorrhage  after  a  long  labor  than  a  short 
one,  and  we  may  expect  a  more  complete  expulsion  of  the  placenta  in 
the  latter.     It  is  also  clear,  from  cases  in  my  own  experience,  that  the 

^  Churchill's  Theory  and  Practice  of  Midwifery,  p.  102. 


MANAGEMENT  OF  NATURAL  LABOR.  291 

muscular  power  of  the  uterus  is  by  no  means  in  proportion  to  the  gen- 
eral strength  of  tlie  woman.  The  power  to  assist  by  bearing  down  no 
doubt  is,  but  the  independent  power  of  the  organ  itself  does  not  appear 
to  be.  Certainly  some  of  the  most  perfect  in  parturient  power  that 
have  come  under  my  care  Avere  small  women,  with  little  general  mus- 
cular force.  One  little  woman  of  86  pounds  weight  appeared  almost 
to  have  escaped  the  curse  pronounced  upon  Eve ;  and  another,  still 
smaller,  expelled  a  placenta  from  her  vagina  almost  without  any  loss 
of  blood. — Ed.] 

Objections  to  Ordinary  Practice. — This  may  fairly  be  taken  as  a  suffi- 
ciently accurate  description  of  the  practice  usually  followed.^  The 
objections  I  have  to  make  are :  (1)  That  it  inculcates  the  common  error 
of  relying  on  the  binder  as  a  means  of  promoting  uterine  contraction, 
advising  its  application  before  the  expulsion  of  the  placenta ;  while  I 
hold  that  the  binder  should  never  be  applied  until  after  the  placenta  is 
expelled,  and  not  even  then  unless  the  uterus  is  perfectly  and  perma- 
nently contracted.  (2)  That  it  teaches  that  traction  on  the  cord  should 
be  used  as  a  means  of  withdrawing  the  placenta,  whereas  the  uterus 
itself  should  be  made  to  expel  the  after-birth,  and  in  nineteen  cases  out 
of  twenty  the  finger  need  never  be  introduced  into  the  vagina  after  the 
birth  of  the  child,  nor  the  cord  touched.  This  may  seem  an  exaggerated 
statement  to  those  who  have  accustomed  themselves  to  the  usual  method 
of  dealing  with  the  placenta  ;  but  I  feel  confident  that  all  who  have 
learnt  the  method  of  expression  of  the  placenta  would  testify  to  its 
accuracy. 

Expression  of  the  Placenta. — The  cardinal  point  to  bear  in  mind  is, 

^  This  practice  is  further  illustrated  by  the  annexed  diagram,  contained  in  most 
obstetric  works,  which  represents  the  accoucheur  as  withdrawing  the  placenta  by  trac- 
tion, and  which  I  insert  as  an  illustration  of  what  ought  not  to  be  done  (Fig.  107)  : 

Fig.  107. 


Unual  Mciliod  of  Removing  the  Placenta  hy  Traction  on  the  Cord. 


292  LABOR. 

that  the  placenta  should  be  expelled  from  the  uterus  by  a  vis  a  tergo,  not 
drawn  out  by  a  vis  afronte.  That  uterine  pressure  after  the  birth  of 
the  child  has  been  recommended  by  many  English  writers  is  certain,  and 
the  Dublin  school  especially  have  dwelt  on  its  importance  as  a  prevent- 
ive of  post-partum  hemorrhage  ;  but  the  distinct  enunciation  of  the  doc- 
trine that  the  placenta  should  be  pressed,  and  not  drawn,  out  of  the 
uterus,  we  owe  to  Crede  and  other  German  writers ;  and  it  is  only  of 
late  years  that  this  practice  has  become  at  all  common.  Those  who 
have  not  seen  placental  expression  practised  find  it  difficult  to  under- 
stand that  in  the  large  majority  of  cases  the  uterus  may  be  made  to 
expel  the  placenta  out  of  the  vagina ;  but  such  is  unquestionably  the 
fact.  A  little  practice  is  no  doubt  necessary  to  effect  this  satisfactorily  ; 
but  when  once  the  knack  has  been  learnt,  there  is  little  difficulty  likely 
to  be  experienced. 

ImportanGe  of  Not  Removing  the  Placenta  Hurriedly. — Before  describ- 
ing the  method  of  placental  expression  a  word  of  caution  may  be  said 
against  tuidue  haste  in  attempting  expression  of  the  placenta — a  mistake 
that  is  often  made,  and  which,  I  believe,  tends  to  increase  the  risk  of 
post-partum  hemorrhage.  So  long  as  Ave  satisfy  ourselves  that  the 
uterus  is  fairly  contracted,  so  as  to  avoid  the  possibility  of  its  distension 
with  blood,  a  certain  delay  after  the  birth  of  the  child  is  useful,  from  its 
giving  time  for  coagula  to  form  within  the  uterine  sinuses,  by  which 
their  open  mouths  are  closed  up.  The  importance  of  this  point  has  been 
specially  dwelt  upon  by  McClintock,  who  lays  down  the  rule  that  fifteen 
or  twenty  minutes  should  be  allowed  to  elapse  after  the  birth  of  the 
child  before  any  attempt  to  remove  the  after-birth  is  made.  This  is  a 
good  and  safe  practical  rule,  as  it  gives  ample  time  for  the  complete 
detachment  of  the  placenta  and  the  coagulation  of  the  blood  in  the 
uterine  sinuses. 

Mode  of  effecting  Expression  of  the  Placenta. — During  this  interval 
the  practitioner  or  nurse  should  sit  by  the  bedside,  with  the  hand  on 
the  uterus  to  secure  contraction  and  prevent  distension,  but  not  knead- 
ing or  forcibly  compressing  it.  When  we  judge  that  a  sufficient  time 
has  elapsed  we  may  proceed  to  effect  expulsion.  For  this  purpose  the 
fundus  should  be  grasped  in  the  hollow  of  the  left  hand,  the  ulnar  edge 
of  the  hand  being  well  pressed  down  behind  the  fundus,  and  when  the 
uterus  is  felt  to  harden  strong  and  firm  pressui-e  should  be  made  down- 
ward and  backward  in  the  axis  of  the  pelvic  brim.  If  this  manoeuvre 
be  properly  carried  out  and  sufficiently  firm  pressure  made,  in  almost 
every  case  the  uterus  may  be  made  to  expel  the  placenta  into  the  bed, 
along  with  any  coagula  that  may  be  in  its  cavity  (Fig.  108).  The 
uterine  surface  of  the  placenta  is  generally  expelled  first,  as  is  repre- 
sented in  the  diagram,  the  cord  being  within  the  membranes ;  whereas 
the  foetal  surface  and  root  of  the  cord  are  the  parts  which  appear  first 
when  the  placenta  is  removed  by  traction  (Fig.  107).  If  _we  do  not 
succeed  at  the  first  effort,  which  is  rarely  the  case  if  extrusion  be  not 
attempted  too  soon  after  the  birth  of  the  child,  we  may  wait  until 
another  contraction  takes  place,  and  then  reapply  the  pressure.  I  repeat 
that,  after  a  little  practice,  the  placenta  may  be  entirely  expelled  in  this 
way,  in  nineteen  cases  out  of  twenty,  without  even  touching  the  cord, 


MANAGEMENT  OF  NATURAL  LABOR. 


293 


and  the  bugbear  of  retained  placenta  will  cease  to  be  a  source  of 
dread. 

Should  we  fail  in  causing  the  uterus  to  expel  the  placenta,  a  vaginal 
examination  may  be  made,  and,  if  the  placenta  be  found  lying  entirely 
in  the  vagina,  it  may  be  carefully  withdrawn.  If,  however,  the  cord 
can  be  traced  up  through  the  os,  showing  that  the  placenta  is  still  within 
the  uterine  cavity,  we  must  again  resort  to  pressure  to  effect  its  expul- 
sion, and  not  attempt  to  withdraw  it  by  traction.  Such  cases  may 
fairly  be  classed  as  retained  placenta,  but  they  should  be  very  rarely 
met  with,  and  are  discussed  elsewhere.  When  they  do  occur  often  in 
the  hands  of  the  same  practitioner,  it  is  fair  to  conclude  that  he  has 
not  properly  acquired  the  art  of  managing  this  stage  of  labor.  Gener- 
ally speaking,  the  placenta  should  be  expelled  within  twenty  minutes 

Fig.  108. 


Illustrating  Expression  of  the  Placenta. 

after  the  birth  of  the  child,  but  no  doubt  in  the  large  majority  of  cases 
expulsion  might  be  effected  sooner  were  it  advisable  to  attempt  it. 

Management  of  the  Membranes. — When  the  mass  of  the  placenta  is 
expelled,  the  membranes  generally  still  remain  in  the  vagina,  and  they 
should  be  tinsted  into  a  rope  and  very  gently  withdrawn,  so  as  not 
to  leave  any  portion  behind.  This  is  a  precaution  the  importance  of 
which  I  would  strongly  urge,  for  I  believe  that  the  chance  of  part  of 
the  membranes  being  torn  off  and  left  in  utero  is  the  one  objection  to 
the  method  recommended.  With  due  care,  however,  this  accident  may 
be  avoided ;  and  the  risk  will  be  lessened  if  the  placenta  is  received  into 
the  palm  of  the  right  hand,  on  expression,  so  as  to  avoid  any  strain  on 
the  membranes. 

(hmpreHdon  of  the  Uterua  after  the  Expulsion  of  the  Placenta,. — The 
duties  of  the  medical  attendant  are  not  even  now  over.  For  at  least 
ten  minutes  after  the  extrusion  of  the  placenta  he  should  keep  his  hand 
on  the  firmly-contracted  uterus,  gently  kneading  it,  without  any  force, 
for  the  purpose  of  promoting  firm  and  equable  contraction  and  causing 
it  to  throw  off  the  coagula  that  may  form  in  its  cavity. 


294  LABOR. 

Administration  of  Ergot  of  Bye. — The  sul)sequent  comfort  and  safety 
of  the  patient  may  be  promoted  by  administering  at  this  time  a  full  dose 
of  ergot  of  rye,  such  as  a  drachm  or  more  of  the  liquid  extract.  The 
property  possessed  by  this  drug  of  producing  tonic  and  persistent  con- 
traction of  the  uterine  fibres,  which  renders  it  of  doubtful  utility  as  an 
oxytocic  during  labor,  is  of  special  value  after  delivery,  when  such  con- 
traction is  precisely  what  ^ve  desire.  I  have  long  been  in  the  habit  of 
administering  the  drug  at  this  period,  and  believe  it  to  be  of  great  value, 
not  only  as  a  prophylactic  against  hemorrhage,  but  as  a  means  of  lessen- 
ing after-pains. 

Application  of  the  Binder. — AVhen  we  are  satisfied  that  the  uterus  is 
permanently  contracted  we  may  apply  the  binder,  but  this  should  rarely 
be  done  until  at  least  half  an  hour  after  the  birth  of  the  child.  The 
soiled  clothes  should  be  gently  withdrawn  from  under  the  patient,  mov- 
ing her  as  little  as  possible,  and  the  binder  should  be,  at  the  same  time, 
slipped  under  the  body,  taking  care  that  it  is  passed  well  below  the  hips, 
so  as  to  secure  a  firm  hold.  No  kind  of  bandage  is  better  than  a  piece 
of  stout  jean,  of  sufficient  breadth  to  extend  from  the  trochanters  to 
the  ensiform  cartilage :  a  jack-towel  or  bolster  slip  answers  the  pur- 
pose very  well.  These  are  preferable,  at  any  rate  at  first,  to  the  shaped 
binders  that  are  often  used.  One  or  two  folded  napkins  are  gener- 
ally placed  over  the  uterus,  so  as  to  form  a  pad  to  keep  up  pressure. 
Once  in  position,  the  binder  is  pulled  tight  and  fastened  by  pins.  The 
utility  of  careful  bandaging  after  delivery  can  scarcely  be  doubted, 
although  some  years  ago  it  became  the  fashion  to  dispense  with  it.  It 
gives  a  comfortable  support  to  the  lax  abdominal  walls,  keeps  up  a  cer- 
tain amount  of  pressure  on  the  uterus,  and  tends  to  restore  the  figure  of 
the  patient.  After  the  bandage  is  applied  a  warm  napkin  should  be 
placed  on  the  vulva  as  a  means  of  estimating  the  quantity  of  the  dis- 
charge, and  the  patient  may  be  allowed  to  rest. 

After-Treatment. — Unless  the  labor  have  been  very  long  and  fatiguing, 
an  opiate,  often  exhibited  as  a  matter  of  routine,  is  unadvisable,  although 
it  may  be  well  to  leave  one  with  the  nurse,  to  be  given  if  the  patient 
cannot  sleep  or  if  the  after-pains  be  very  troublesome.  The  practitioner 
may  now  leave  the  room,  but  not  the  house,  and  at  least  an  hour  should 
elapse  after  delivery  before  he  takes  his  departure.  Before  doing  so  he 
should  visit  the  j)atient,  inspect  the  napkin  to  see  that  there  is  not  too 
much  discharge,  and  satisfy  himself  that  the  uterus  is  contracted  and 
not  distended  with  coagula.  He  should  also  count  the  pulse,  which, 
if  the  patient  be  progressing  satisfactorily,  will  be  found  at  its  normal 
average.  If,  however,  it  be  beating  over  100  per  minute,  he  should  on 
no  account  leave,  for  such  a  rapidity  of  the  circulation  renders  it 
extremely  probable  that  hemorrhage  is  impending.  This  is  a  good 
practical  rule,  laid  down  by  McClintock  in  his  excellent  paper  "  On 
the  Pulse  in  Childbed,"  attention  to  which  may  often  save  the  patient 
from  disastrous,  consequences. 

Before  leaving,  the  practitioner  should  see  that  the  room  is  darkened, 
all  bystanders  excluded,  and  the  patient  left  as  quiet  as  possible  to 
recover  from  the  shock  of  labor. 


ANESTHESIA  IN  LAB  OB.  295 


CHAPTER   IV. 

ANESTHESIA   IN  LABOR 

A  FEW  words  may  be  said  as  to  the  use  of  ansesthetics  during  labor — 
a  practice  which  has  become  so  universal  that  no  argument  is  required 
to  establish  its  being  a  perfectly  legitimate  means  of  assuaging  the  suf- 
ferings of  childbirth.  Indeed,  the  tendency  in  the  present  day  is  in  the 
opposite  direction,  and  a  common  error  is  the  administration  of  chloro- 
form to  an  extent  which  materially  interferes  with  the  uterine  contrac- 
tions and  predisposes  to  subsequent  post-partum  hemorrhage. 

Agents  Employed. — Practically  speaking,  the  only  agent  hitherto  em- 
ployed in  this  country  is  chloroform,  although  the  bichloride  of  methy- 
lene and  ether  have  been  occasionally  tried.  Of  late  years,  chloral  has 
been  extensively  used  by  some,  and,  as  I  believe  it  to  be  an  agent  of 
very  great  value,  I  shall  first  indicate  the  circumstances  under  which  it 
may  be  employed. 

Chloral. — The  peculiar  value  of  chloral  in  labor  is  that  it  may  be 
safely  administered  at  a  time  when  chloroform  cannot  be  generally  em- 
ployed. The  latter,  while  it  annuls  suffering,  very  frequently  tends  in  a 
marked  degree  to  diminish  uterine  action.  This  is  a  familiar  observation 
to  all  who  have  employed  it  much  during  labor,  as  the  diminution  of 
the  force  and  intensity  of  the  pains,  and  the  consequent  retardation  of 
the  labor,  often  oblige  us  to  suspend  its  inhalation,  at  least  temporarily. 
Indeed,  this  very  property  of  annulling  uterine  action  is  one  of  its  most 
valuable  qualities  in  obstetrics,  as  in  certain  cases  of  turning.  For  such 
purposes  it  is  necessary  to  give  it  to  the  surgical  extent,  which  we 
endeavor  to  avoid  when  it  is  used  simply  to  lessen  the  suffering  of  ordi- 
nary lal)or.  Still,  it  is  not  always  easy  to  limit  its  action  in  this  way, 
and  thus  it  very  frequently  does  more  than  we  wish.  Such  diminution 
in  the  intensity  of  uterine  contraction  is  comparatively  of  less  conse- 
quence in  the  propulsive  stage,  and  it  is  generally  more  than  counter- 
balanced by  the  relief  it  affords.  In  the  first  stage  it  is  otherwise,  and, 
pi'actically  speaking,  chloroform  is  generally  not  admissible  until  the 
head  is  in  the  pelvic  cavity. 

Chloral  is  especially  the  Ancesthetio  of  the  First  Stage. — Chloral,  on  the 
other  hand,  has  no  such  relaxing  effects  on  uterine  contraction.  It  cannot, 
it  is  true,  compete  with  chloroform  in  its  power  of  relieving  pain,  but  it 
produces  a  drowsy  state  in  which  tlie  pain  is  not  felt  nearly  so  acutely  as 
befon;.  It  is  tli(;refore  in  the  first  stage  of  labor,  while  the  pains  are 
cutting  and  grinding,  and  during  the  dilatation  of  the  cervix,  that  it  finds 
its  most  useful  apj)licatiou.  It  is  es])e(*ially  valuable  in  those  cases,  so 
frequently  met  with  in  the  upjjcr  classes,  in  which,  the  pains  produce 
intolerably  acute  suffering,  but  with  little  effect  on  the  progress  of  the 
labor.  In  them  the  os  is  often  thin  and  rigid  and  the  pains  \cry  fre- 
quent and  acute,  but  little  or  no  dilatation  is  effected.    When  the  j)atient 


296  LABOR. 

is  brought  under  the  influence  of  chloral,  however,  the  pains  become  less 
frequent  but  stronger,  nervous  excitement  is  calmed,  and  the  dilatation  of 
the  cervix  often  proceeds  rapidly  and  satisfactorily.  Indeed,  I  know  of 
nothing  which  answers  so  well  in  cases  of  rigid,  undilatable  cervix,  and 
I  believe  its  administration  to  be  far  more  effective,  under  such  circum- 
stances, than  any  of  the  remedies  usually  employed. 

Object  and  Mode  of  Administration. — The  object  is  to  produce  a  som- 
nolent condition  which  shall  be  protracted  as  long  as  possible.  For  this 
purpose  15  grains  of  chloral  may  be  administered  every  twenty  minutes 
until  three  doses  are  given.  This  generally  suffices  to  produce  the  de- 
sired effect.  The  patient  becomes  very  drowsy,  dozes  between  the  pains, 
and  wakes  up  as  each  contraction  commences.  It  may  be  necessary  to 
give  a  fourth  dose  at  a  longer  interval,  say  an  hour  after  the  third  dose, 
to  keep  up  and  prolong  the  soporific  action  ;  but  this  is  seldom  necessary, 
and  I  have  rarely  given  more  than  a  drachm  of  chloral  during  the  entire 
progress  of  labor.  Another  advantage  of  this  treatment  is  that,  while 
it  does  not  interfere  with  the  use  of  chloroform  in  the  second  stage,  it 
renders  it  necessary  to  give  less  than  otherwise  would  be  called  for,  and 
thus  its  action  can  be  more  easily  kept  within  bounds.  On  the  whole, 
therefore,  I  am  inclined  to  consider  chloral  a  very  valuable  aid  in  the 
management  of  labor,  and  believe  that  it  is  destined  to  be  much  more 
extensively  used  than  is  at  present  the  case.  So  far  as  my  experience 
has  yet  gone,  I  have  not  met  wath  any  symptoms  which  have  led  me  to 
think  that  it  has  produced  bad  effects  ;  and  I  have  known  many  patients 
sleep  quietly  through  labor,  without  expressing  any  excessive  suffering 
or  asking  for  chloroform,  who  under  ordinary  circumstances  would  have 
been  most  urgently  calling  for  relief.  It  occasionally  happens  that  the 
patient  cannot  retain  the  chloral  from  its  tendency  to  produce  sickness  ; 
it  may  then  be  readily  given  per  rectum  in  the  form  of  enema. 

Chloroform. — Generally  speaking,  we  do  not  think  of  giving  chloro- 
1  form  until  the  os  is  fully  dilated,  the  head  descending,  and  the  pains 
I  becoming  propulsive.     It  has  often,  indeed,  been  administered  earlier, 
for  the  purpose  of  aiding  the  dilatation  of  a  rigid  cervix  ;  and  there  is 
no  doubt  that  it  often  succeeds  well  when  employed  in  this  way,  but  I 
have  already  stated  my  belief  that  chloral  answers  this  purpose  better. 
I      Only  to  be  Given  during  the  Pains. — There  is  one  cardinal  rule  to  be 
remembered  in  giving  chloroform  during  the  propulsive  stage,  and  that 
j  is  that  it  should  be  administered  intermittently,  and  never  continuously. 
I  When  the  pain  comes  on  a  few  drops  may  be  scattered  over  a  Skinner's 
I  inhaler,  which  affords  one  of  the  best  means  of  administering  it  in  labor, 
;  or  placed  within  the  folds  of  a  handkerchief  twisted  into  the  form  of  a 
cone.     During  the  acme  of  the  pain  the  patient  inhales  it  freely,  and  at 
once  experiences  a  sense  of  great  relief;   and  as  soon  as  the  ])am  dies 
away  the  inhaler  should  be  removed.    In  the  interval  between  the  pains 
}  the  effect  of  the  drug  passes  off,  so  that  the  higher  degree  of  anaesthesia 
( should  never  be  produced.     Indeed,  when  properly  given  consciousness 
should  not  be  entirely  abolished,  and  the  patient,  between  the  pains, 
should  be  able  to  speak  and  understand  what  is  said  to  her.    This  inter- 
mittent  administration   constitutes  the    peculiar  safety   of    chloroform 
administered  in  labor ;  and  it  is  a  fortunate  circumstance  that,  as  yet. 


ANESTHESIA  IN  LABOR.  297 

there  is,  I  believe,  no  case  on  record  of  death  during  the  inhalation  of 
chloroform  for  obstetric  purposes.  [^]  This  is  obviously  due  to  the  effect 
of  each  inhalation  passing  off  before  a  fresh  dose  is  administered. 

The  effect  on  the  pains  should  be  carefully  watched.     If  they  become  j 
very  materially  lessened  in  force  and  frequency,  it  may  be  necessary  to 
stop  the  inhalation  for  a  short  time,  commencing  again  when  the  pains  | 
get  stronger ;  which  effect  may  be  often  completely  and  easily  prevented  I 
by  mixing  the  chloroform  with  about  one-third  of  absolute  alcohol,  which, 
originally  recommended,  I  believe,  by  Dr.  Sansom,  increases  the  stimu- 
lating effects  of  chloroform,  and  thus  diminishes  its  tendency  to  produce 
undue  relaxation.     The  amount  administered  must  vary,  of  course,  with 
the  peculiarities  of  each  individual  case  and  the  effect  produced,  but  it 
need  never  be  large.     As  the  head  distends  the  perineum  and  the  pains 
get  very  strong  and  forcing,  it  may  be  given  more  freely,  and  to  the* 
extent  of  inducing  even  complete  insensibility  just  before  the  child  is 
born. 

Ether  as  a  Substitute  for  Chloroform. — In  cases  in  which  chloroform  ' 
has  lessened  the  force  of  the  pains  ether  may  be  given  instead  with  great  i 
advantage.    It  certainly  often  acts  well  when  chloroform  is  inadmissible  i 
on  account  of  its  effects  on  the  pains,  and,  so  far  as  my  experience  goes, 
it  has  not  the  property  of  relaxing  the  uterus,  but,  on  the  contrary,  has  ^ 
sometimes  seemed  to  me  distinctly  to  intensify  the  pains.      Of  late  I 
have  used  a  mixture  of  one  part  of  absolute  alcohol,  two  of  chloroform, 
and  three  of  ether.     This  is  less  disagreeable  than  ether,  and  has  not  the 
over-relaxing  effects  of  chloroform. 

Precautions. — Bearing  in  mind  the  tendency  of  chloroform  to  produce 
uterine  relaxation,  more  than  ordinary  precautions  should  always  be 
taken  against  post-partum  hemorrhage  in  all  cases  in  which  it  has  been 
freely  administered. 

In  cases  of  operative  midwifery  it  is  often  given  to  the  extent  of  pro- 
ducing complete  ansesthesia.  In  all  such  cases  it  should  be  administered, 
when  possible,  by  another  medical  man,  and  not  by  the  operator,  because 
the  giving  of  chloroform  to  the  surgical  degree  requires  the  undivided 
attention  of  the  administrator,  and  no  man  can  do  this  and  operate  at 
the  same  time.  I  once  learnt  an  important  lesson  on  this  point.  I  had 
occasion  to  apply  the  forceps  in  the  case  of  a  lady  who  insisted  on  hav- 
ing chloroform.  When  commencing  the  operation  I  noticed  some  sus- 
picious appearances  about  the  patient,  who  was  a  large  stout  woman  with 
a  feeble  circulation.  I  therefore  stopped,  allowed  her  to  regain  con- 
sciousness, and  delivered  her  Avithout  anaesthesia,  much  to  her  own 
annoyance.  Just  one  month  after  labor  she  went  to  a  dentist  to  have  a 
tooth  extracted,  and  took  cliloroform,  during  the  inhalation  of  which  she 
died.  This  impressed  on  my  mind  the  lesson  that  no  man  can  do  two 
things  at  the  same  time.  The  partial  unconsciousness  of  incomplete 
anaesthesia,  in  which  the  patient  is  restless  and  tossing  about,  renders 
the  a])plicati(jn  of  forceps,  as  well  as  all  other  operations,  very  difficult. 

\}  In  the  Iravmclioriif  of  the  Amerinan  Gipufcnlor/iml  Society  for  the  year  1877  are  five 
caHCH  of  oil loroforrn-]Kiisf)ninK  occurring  in  ohstetriojil  cnscs.  reiiorted  l)ypr.  \V.  T.  Lnsk 
of  New  York.  In  three,  restoratii^n  was  elleeted  by  artificial  respiration,  but  in  two 
death  resulted  absolutely.— Ed.] 


298  LAB  OB. 

Therefore,  unless  the  patient  can  be  completely  and  fully  ansesthetized, 
it  is  better  to  operate  without  chloroform  being  given  at  all. 

[In  the  United  States  the  dangers  attending  the  use  of  chloroform  in 
obstetric  practice  have,  in  large  measure,  banished  it  from  the  lying-in 
chamber.  Some  obstetricians  in  our  chief  cities  still  resort  to  it  with 
little  hesitation,  believing  that  by  great  carefulness  in  its  administration, 
and  by  the  substitution  of  ether  in  exceptional  cases,  all  danger  may  be 
avoided.  Others  have  a  very  great  fear  of  it,  and  universally  trust  to 
the  safer  ansesthetic.  It  is  an  error  to  suppose  that  the  parturient  state 
robs  chloroform  of  much  of  its  danger,  the  apparent  immunity  being 
due  to  its  intermittent  and  incomplete  administration ;  complete  anaes- 
thesia being  but  a  fraction  less  dangerous  than  in  surgical  operations 
upon  women  who  are  not  pregnant.  Dr.  Lusk,  already  quoted,  after  a 
•  large  experience  with  the  use  of  chloroform,  says  :  "  Patients  in  labor  do 
not  enjoy  any  absolute  immunity  from  the  pernicious  effects  of  chloroform." ' 
It  is  much  to  be  regretted  that  this  more  pleasant  anaesthetic  is  so  much 
more  dangerous  than  ether  as  an  inhalant ;  but  in  consideration  of  the 
difference  of  risk,  that  of  their  relative  effects  upon  the  nose  and  trachea 
is  scarcely  to  be  considered.  Chloroform  acts  upon  the  respiratory  cen- 
tres just  as  ether  does ;  and  this  is  an  element  of  danger  in  each,  but  is 
capable  of  being  counteracted  by  artificial  respiration.  But,  beyond  this, 
chloroform  is  far  more  dangerous,  in  acting  upon  the  motor  ganglia  of 
the  heart  and  producing  sudden  death.  According  to  the  experiments 
of  Vulpian  upon  animals,  not  more  than  one  case  of  cardiac  failure  in 
forty  can  be  restored  by  artificial  respiration.  He  affirms  that  there  is 
clanger  at  the  commencement,  during  the  course,  and  at  the  close  of 
chloroformization,  and  even  some  hours  or  days  subsequent  to  it.  Nela- 
ton  made  the  important  discovery  that  the  cerebral  anemia  produced  by 
chloroform,  with  its  accompanying  death-like  condition,  might  be  reme- 
died by  long  perseverance  in  artificial  respiration  with  the  patient  turned 
head  downward. 

Anaesthesia  in  labor  is  much  less  popular,  both  with  obstetricians  and 
patients  in  this  country,  than  it  was  soon  after  its  introduction.  Improve- 
ments in  the  purity  of  sulphuric  ether  have  made  the  narcosis  more  relia- 
ble, but  the  general  effect  upon  patients  varies  very  decidedly,  being  all 
that  can  be  desired  in  some,  and  just  the  reverse  in  others.  Some  of  the 
undesirable  effects  I  have  witnessed  are  intoxication,  with  cessation  of 
labor,  hysterical  excitement,  nightmare,  and  post-partum  inertia  and 
hemorrhage.  I  have  also  witnessed  the  most  delightful  results  from 
ether  that  could  be  desired.  In  a  small,  delicate  multipara,  whose  mother 
died  of  phthisis,  and  to  whom  I  had  been  obliged  to  administer  stimu- 
lants in  the  first  and  much  of  the  second  stage  of  labor,  the  use  of  ether 
had  the  effect  to  revolutionize  her  condition.  Her  pulse  became  strong  ; 
her  expulsive  power  increased ;  she  had  no  suffering  :  her  placenta  was 
expelled  without  accompanying  blood ;  and  there  was  no  subsequent  ute- 
rine relaxation.     But  such  cases  are,  unfortunately,  exceptional. — Ed.] 

[^  Opus  cit.l 


PELVIC  PRESENTATIONS.  299 


CHAPTER   V. 

PELVIC  PRESENTATIONS. 

Under  the  head  of  pelvic  presentations  it  is  customary  to  inchide  all 
cases  in  which  any  part  of  the  lower  extremities  of  the  child  presents. 
By  some  these  are  further  subdivided  into  br^eech,  footling,  and  knee  pres- 
entations ;  but,  although  it  is  of  consequence  to  be  able  to  recognize  the 
feet  and  the  knee  when  they  present^  so  far  as  the  mechanism  and  man- 
agement of  delivery  are  concerned  the  cases  are  identical,  and  therefore' 
may  be  most  conveniently  considered  together. 


mon 
accor( 

that  it  presents  more  frequently — viz.  once  in  38.8  labors.  Footling 
presentations  occur  only  once  in  92  cases.  They  are  probably  often  the 
mere  conveti^sion  of  original  breech  presentations,  the  feet  having  come 
down  during  the  labor,  either  in  consequence  of  the  sudden  escape  of 
the  liquor  amnii  when  the  breech  was  still  freely  movable  above  the 
brim,  or  from  some  other  cause.  Knee  presentations  are  extremely  rare, 
as  may  be  readily  understood  if  it  be  borne  in  mind  that  to  admit  them 
the  thighs  must  be  extended,  hence  the  vertical  measurement  of  the  child 
must  be  greatly  increased,  and  therefore  it  could  not  be  readily  accommo- 
dated within  the  uterine  cavity  unless  of  unusually  small  size.  As  a 
matter  of  fact,  Mme.  La  Chapelle  found  only  one  knee  presentation  in 
upward  of  3000  cases. 

Causes. — The  causes  of  pelvic  presentations  are  not  known.  They 
are  probably  the  same  as  those  which  produce  other  varieties  of  mal- 
presentations ;  and  it  is  not  unlikely  that  in  certain  women  there  may 
be  some  peculiarity  in  the  shape  of  the  uterine  cavity  which  favors  their 
production.  It  would  be  difficult  otherwise  to  explain  such  a  case  as 
that  mentioned  by  Velpeau  in  which  the  breech  presented  in  six  labors.  ^ 

Prognosis. — The  results,  as  regards  the  mother,  are  in  no  way  more  J>urt!Vww*. 
unfavorable  than  in  vertex  presentation.     The  first  stage  of  the  labor  is    "VWHivA^ 
generally  tedious,  since  the  large  rounded  mass  of  the  breech  does  not       "^-[u-*^ 
adapt  itself  so  well  as  the  head  to  the  lower  segment  of  the  uterus,  and 
dilatation  of  the  cervix  is  consequently  apt  to  be  retarded.     The  second 
stage  is,  however,  if  anything,  more  rapid  than  in  vertex  cases ;  and 
even  ^vhen  it  is  protracted  the  soft  breech  does  not  produce  such  injuri- 
ous pressure  on  the  maternal  structures  as  the  hard  and  unyielding  head. 

The  Infantile  Mortality  in  Pelvic  Presentations. — The  result  is  very  ,  : 
different  as  regards  the  child.  Dubois  calculated  that  1  out  of  11  chil- 
dren was  stilll>orn.  Clnu'chill  estimates  the  mortality  as  much  higher — 
viz.  1  in  3i.  The  latter  certainly  indicates  a  larger  number  of  stillbirths 
than  is  consistent  with  the  ex])erience  of  most  practitioners,  and  more 
than  should  occur  if  tlie  cases  be  properly  managed ;  but  there  can  be 


^ 


300  LABOR. 

no  doubt  that  the  risk  to  the  child  is,  even  under  the  most  favorable 
circumstances,  very  great.  Even  when  the  child  is  not  lost  it  may  be 
seriously  injured.  Dr.  Ruge  has  tabulated  a  series  of  29  cases  in  which 
there  were  found  to  be  fractures  of  bones  or  other  injuries.^ 
I  Causes  of  Fcetul  3Iortality. — Tlie  chief  source  of  danger  is  pressure 
on  the  umbilical  cord  in  the  interval  elapsing  between  the  birth  of  the 
body  and  the  head.  At  this  time  the  cord  is  very  generally  compressed 
between  the  head  of  the  child  and  the  pelvic  walls,  so  that  circulation  in 
its  vessels  is  arrested.  Hence  the  aeration  of  the  foetal  blood  cannot 
take  place,  and,  pulmonary  respiration  not  having  been  yet  established, 
the  child  dies  asphyxiated.  There  are  other  conditions  present  which 
tend,  although  in  a  minor  degree,  to  produce  the  same  result.  One  of 
these  is  that  the  placenta  is  probably  often  separated  by  the  uterine  con- 
tractions when  the  bulk  of  the  body  is  being  expelled,  as,  indeed,  takes 
place,  under  analogous  circumstances,  when  the  vertex  presents,  the 
necessary  result  being  the  arrest  of  placental  respiration.  Joulin  thinks 
that  the  same  effect  may  be  produced  by  the  compression  of  the  placenta 
l)etween  the  contracted  uterus  and  the  hard  mass  of  the  foetal  skull. 
Probably  all  these  causes  combine  to  arrest  the  functions  of  the  placenta, 
and  if  the  delivery  of  the  head,  and  consequently  the  establishment  of 
pulmonary  respiration,  be  delayed,  the  death  of  the  child  is  almost 
inevitable.  The  corollary  is,  that  the  danger  to  the  child  is  in  direct 
proportion  to  the  length  of  time  that  elapses  between  the  birth  of  the 
body  and  that  of  the  head. 

The  risk  to  the  child  is  greater  in  footling  than  in  breech  cases, 
because  in  the  former  the  maternal  structures  are  less  perfectly  dila- 
ted in  consequence  of  the  small  size  of  the  feet  and  thighs,  and  there- 
fore the  birth  of  the  head  is  more  apt  to  be  delayed. 

Diagnosis. — Inasmuch  as  the  long  axis  of  the  child  corresj)onds  with 
the  long  axis  of  the  uterus  in  pelvic  as  in  vertex  presentations,  there  is 
nothing  in  the  shape  of  the  uterus  to  arouse  suspicion  as  to  the  character 
of  the  case.  Still,  it  is  often  sufficiently  easy  to  recognize  a  pelvic  pres- 
entation by  abdominal  examination  if  we  have  occasion  to  make  one. 
The  facility  with  wdiich  it  may  be  done  depends  a  good  deal  on  the 
individual  patient.  If  she  be  not  very  stout,  and  if  the  abdominal 
parietes  be  lax  and  non-resistant,  we  shall  generally  be  able  to  feel  the 
round  head  at  the  upper  part  of  the  uterus,  much  firmer  and  more 
defined  in  outline  than  the  breech.  The  conclusion  will  be  fortified  if 
we  hear  the  foetal  heart  beating  on  a  level  with  or  above  the  umbilicus. 
The  greater  resistance  on  one  side  of  the  abdomen  will  also  enable  us  to 
decide  \\ith  tolerable  accuracy  to  which  side  the  back  of  the  child  is 
placed.  Information  thus  acquired  is,  at  the  best,  uncertain,  and  we 
can  never  be  quite  sure  of  the  existence  of  a  pelvic  presentation  until  we 
can  corroborate  the  diagnosis  by  vaginal  examination. 

Results  of  Vaginal  Examination. — The  first  circumstance  to  excite 
suspicion  on  examination  per  vaginam,  even  when  the  os  is  undilated,  is 
the  absence  of  the  hard  globular  mass  felt  through  the  low^r  segment  of 
the  uterus,  so  characteristic  of  vertex  presentations.  When  the  os  is 
sufficiently  open  to  allow  the  membranes  to  protrude,  although  the  pre- 

^  Bull.  gen.  de  Tlierap.,  August,  1875. 


PELVIC  PRESENTATIONS. 


301 


senting  part  is  too  high  up  to  be  within  reach,  we  may  be  struck  with  \ 
the  peculiar  shape  of  the  bag  of  membranes,  which,  instead  of  being  ' 
rounded,  projects  a  considerable  distance  through  the  os,  like  the  finger 
of  a  glove.  This  is  a  peculiarity  met  with  in  all  mal-presentations 
alike,  and  is,  indeed,  much  less  distinct  in  breech  than  in  footling  pres- 
entations, because  in  the  former  the  membranes  are  more  stretched, 
just  as  they  are  in  vertex  cases.  When  the  membranes  rupture,  instead 
of  the  waters  dribbling  away  by  degrees,  they  often  escape  with  a  rush, 
in  consequence  of  the  pelvic  extremity  not  filling  up  the  lower  part  of 
the  uterus  so  accurately  as  the  head,  which  acts  as  a  sort  of  ball-valve 
and  prevents  the  sudden  and  complete  discharge  of  the  waters. 

Diagnosis  of  the  Breech. — Often,  on  first  examining,  even  when  the 
membranes  are  ruptured,  the  presentation  is  too  high  up  to  be  made 
out  accurately.  All  that  we  can  be  certain  of  is  that  it  is  not  the  head  ; 
and  the  case  must  be  carefully  watched  and  examinations  frequently 
repeated  until  the  precise  nature  of  the  presentation  can  be  established. 
If  the  breech  present,  the  finger  first  impinges  on  a  round,  soft  prom- 
inence, on  depressing  which  a  bony  protuberance,  the  trochanter  major, 
can  be  felt.  On  passing  the  finger  upward  it  reaches  a  groove,  beyoncl 
which  a  similar  fleshy  mass,  the  other  buttock,  can  be  felt.  In  this 
groove  various  characteristic  points,  diagnostic  of  the  presentation,  can 
be  made  out.  Toward  one  end  we  can  feel  the  movable  tip  of  the 
coccyx,  and  above  it  the  hard  sacrum  with  its  rough  projecting  prom- 
inences. These  points,  if  accurately  made  out,  are  quite  characteristic, 
and  resemble  nothing  in  any  other  presentation.  In  front  there  is  the 
anus,  in  which  it  is  sometimes,  but  by  no  means  always,  possible  to 
insert  the  tip  of  the  finger.  If  this  can  be  done,  it  is  easy  to  distinguish 
it  from  the  mouth,  with  which  it  might  be  confounded,  by  observing 
that  the  hard  alveolar  ridges  are  not  contained  within  it.  Still  more  in 
front  we  may  find  the  genital  organs,  the  scrotum  in  male  children 
being  often  much  swollen  if  the  labor  has  been  protracted.  Thus  it  is 
often  possible  to  recognize  the  sex  of  the  child  before  birth. 

Differential  Diagnosis. — The  breech  might  be  mistaken  for  the  face, 
especially  if  the  latter  be  much  swollen ;  but  this  mistake  can  readily  be 
avoided  by  feeling  the  spinous  processes  of  the  sacrum. 

The  knee  is  recognized  by  its  having  tw^o  tuberosities  with  a  depres- 
sion between  them.     It  might  be  confounded  with  the  heel,  the  elbow, 
the  shoulder.     From  the  heel  it  is  distinguished  by  having  two 


! 


or 


tuberosities  instead  of  one ;  from  the  elbow,  by  the  latter  having  one 
sharp  tuberosity,  with  a  depression  on  one  side,  instead  of  a  central 
depression  and  two  lateral  prominences ;  and  from  the  shoulder,  by  the 
lattei-  being  more  rounded,  liaving  only  one  prominence,  running  from 
which  the  acromion  and  clavicle  can  be  traced. 

Diagnosis  of  the  Foot — The  foot  may  be  mistaken  for  the  hand. 
This  error  will  be  avoided  })y  remembering  that  all  the  toes  are  in  the 
samt!  lino,  and  that  tlie  groat  toe  cannot  be  ))rought  into  a})])osition  with 
the  otliors,  as  tlie  tliurni)  can  with  the  fingers.  The  internal  border  of 
the  foot  is  much  thicker  than  the  external,  whereas  the  two  borders  of 
the  hand  are  oi'  the  same  tl)i(;kn('ss.  Moi-eover,  the  foot  is  articulated 
at  right  angles  to  the  leg,  and  cannot  be  brought  into  a  line  with  it,  as 


302  LABOR. 

the  hand  can  with  the  arm.  Finally,  the  projection  of  the  calcaneum  is 
characteristic,  and  resembles  nothing  in  the  hand. 

Mechanism. — As  is  the  case  in  other  presentations,  obstetricians  have 
very  variously  subdivided  breech  presentations,  with  the  effect  of  need- 
lessly complicating  the  subject.  The  simplest  division,  and  that  which 
will  most  readily  impress  itself  on  the  memory  of  the  student,  is  to 
describe  the  breech  as  presenting  in  four  positions,  analogous  to  those  of 
the  vertex,  the  sacrum  being  taken  as  representing  the  occiput,  and  the 
positions  being  numbered  according  to  the  part  of  the  pelvis  to  which 
it  points.     Thus  we  have — 

First,  or  left  sacro-anterior  (corresponding  to  the  first  position  of  the 
vertex).  The  sacrum  of  the  child  points  to  the  left  foramen  ovale  of 
the  mother. 

Second,  or  right  sacro-anterior  (corresponding  to  the  second  vertex 
position).  The  sacrum  of  the  child  points  to  the  right  foramen  ovale 
of  the  mother. 

Third,  or  right  sacro-posterior  (corresponding  to  the  third  vertex 
position).  The  sacrum  of  the  child  points  to  the  right  sacro-iliac 
synchondrosis  of  the  mother. 

Fourth,  or  left  sacro-posterior  (corresponding  to  the  fourth  vertex 
]30sition).  The  sacrum  of  the  child  points  to  the  left  sacro-iliac 
synchondrosis  of  the  mother, 

Of  these,  as  with  the  corresponding  vertex  positions,  the  first  and 
third  are  the  most  common,  their  comparative  frequency,  no  doubt, 
depending  on  the  same  causes.  The  mechanical  conditions  to  which  the 
presenting  part  is  subjected  are  also  identical,  but  the  alterations  of  posi- 
tion of  the  breech  in  its  progress  are  by  no  means  so  uniform  as  those 
of  the  head,  on  account  of  its  less  perfect  adaptation  to  the  pelvic  cavity. 
The  mechanism  of  the  delivery  of  the  shoulders  and  head  in  breech 
presentations,  moreover,  is  of  much  greater  practical  importance  than 
that  of  the  body  in  vertex  presentations,  inasmuch  as  the  safety  of  the 
child  depends  on  its  speedy  and  satisfactory  accomplishment.  Bearing 
these  facts  in  mind,  it  will  suffice  to  descriloe  briefly  the  phenomena  of 
delivery  in  the  first  and  third  breech  positions. 

Position  of  the  Child  at  Brim. — In  the  first  position  (Fig.  109)  the 
sacrum  of  the  child  points  to  the  left  foramen  ovale ;  its  back  is  conse- 
quently placed  to  the  left  side  of  the  uterus  and  anteriorly,  and  its  abdo- 
men looks  to  the  right  side  of  the  uterus  and  posteriorly.  The  sulcus 
between  the  buttocks  lies  in  the  right  oblique  diameter  of  the  pelvis, 
while  the  transverse  diameter  of  the  buttocks  lies  in  the  left  oblique 
diameter,  the  left  buttock  being  most  easily  within  reach.  As  in  vertex 
presentations,  the  hips  of  the  child  lie  on  the  same  level  at  the  pelvic 
brim,  although  Naegele  describes  the  left  hip  as  placed  lower  than  the 
right. 

Descent. — As  the  pains  act  on  the  body  of  the  child  the  breech  is 
gradually  forced  through  the  pelvic  cavity,  retaining  the  same  relations 
as  at  the  brim,  its  progress  being  generally  more  slow  than  that  of  the 
head,  until  it  reaches  the  lower  pelvic  strait,  when  the  same  mechanism 
which  produces  rotation  of  the  occiput  comes  to  operate  upon  it.  The 
result  is  a  rotation  of  the  child's  pelvis,  so  that  its  transverse  diameter 


PELVIC  PRESENTATIONS. 


303 


comes  to  lie  approximately  in  the  antero-posterior  diameter  of  the  out- 
let ;  its  antero-posterior  diameter  corresponds  to  the  transverse  diameter 
of  the  mother's  pelvis,  the  left  hip  lies  behind  the  pubes,  and  the  right 
toward  the  sacrum.  This  rotation,  which  is  admitted  by  the  majority 
of  obstetricians,  is  altogether  denied  by  Naegele.  There  can  be  no 
doubt,  however,  that  it  does  generally  take  place,  but  by  no  means  so 
constantly  as  the  corresponding  rotation  of  the  vertex ;  and  it  is  not 
uncommon  for  it  to  be  entirely  absent  and  for  the  hips  to  be  born  in  the 
oblique  diameter  of  the  outlet.  The  body  of  the  child  is  said  frequently 
not  to  follow  the  movement  imparted  to  the  hips,  so  that  there  is  more 
or  less  of  a  twist  in  the  vertebral  column. 

Expulsion  of  the  Hips  and  Body. — The  left  hip  now  becomes  firmly 
fixed  behind  the  pubes,  and  a  movement  of  extension,  analogous  to  that 

Fm.  109. 


First,  or  Left  Sacro-anterior,  Position  of  the  Breech. 

of  the  head  in  vertex  presentations,  takes  place.  The  right,  or  posterior, 
hip  revolves  round  the  fixed  one,  gradually  distends  the  perineum,  and 
is  expelled  first,  the  left  hip  rapidly  following.  As  soon  as  both  hips 
are  born  the  feet  slip  out,  unless  the  legs  are  completely  extended  upon 
the  child's  abdomen.  The  shoulders  soon  follow,  lying  in  the  left  oblique 
diameter  of  the  pelvis  (Fig.  110).  The  left  shoulder  rotates  forward 
behind  the  pubes,  where  it  becomes  fixed,  the  right  shoulder  sweeping 
over  the  perineum  and  being  born  first.  The  arms  of  the  child  are 
generally  found  placed  upon  its  thorax,  and  are  born  before  the  shoulders. 
Sometimes  they  are  extended  over  the  child's  head,  thus  causing  consid- 
erable delay  and  greatly  increasing  the  risk  to  the  child.  It  is  now  gen- 
erally admitted  that  such  e\-t(!iision  is  most  aj)t  to  occur  when  traction 
has  been  made  on  the  child's  body  with  the  view  of  hastening  delivery, 
and  that  it  is  rarely  met  with  when  the  expulsion  of  the  body  is  left 
entirely  to  the  natural  powers. 


304 


LABOR. 


Delivery  of  the  Head. — When  the  shoulders  are  expelled  the  head 
enters  the  pelvis  in  the  opposite,  or  right  oblique,  diameter,  the  face 
looking  to  the  right  sacro-iliac  synchondrosis.     As  the  greater  part  of 


Fig.  110. 


Passage  of  the  Shoulders  and  Partial  Rotation  of  the  Thorax. 

the  child  is  now  expelled,  and  as  the  head  has  entered  the  vagina,  the 
uterus,  having  a  comparatively  small  mass  to  contract  upon,  must  obvi- 
ously act  at  a  mechanical  disadvantage.  Still,  the  pressure  of  the  head 
on  the  vagina  is  a  powerful  inciter,  the  accessory  muscles  of  parturition 
are  brought  into  strong  action,  and  there  may  be  sufficient  force  to  ensure 
I  expulsion  of  the  head  without  artificial  aid.  On  account  of  the  great 
resistance  to  the  descent  of  the  occiput  from  its  articulation  with  the 
'spinal  column,  the  pains  have  the  effect  of  forcing  down  the  anterior 
'portion  of  the  head,  and  this  ensures  the  complete  flexion  of  the  chin 
upon  the  sternum  (Fig,  111).  This  is  a  great  advantage  from  a  mechan- 
ical point  of  view,  as  it  causes  the  short  occipito-mental  diameter  of  the 

Fig.  111. 


Descent  of  the  Head. 


head  to  enter  the  pelvis  in  the  axis  of  the  uterus  and  the  brim.  If  the 
head  should  be  in  a  state  of  partial  extension,  as  sometimes  happens 
when  the  pelvis  is  unusually  roomy,  the  occipito-frontal  diameter  is 


PELVIC  PRESENTATIONS.  305 

placed  in  a  similar  relation  to  the  brim — a  position  certainly  less  favor- 
able to  the  easy  birth  of  the  head.  As  the  head  descends  it  experiences 
a  movement  of  rotation,  the  occiput  passing  forward  and  to  the  right, 
behind  the  pubic  arch,  the  face  turning  baclcAvard  into  the  hollow  of  the 
sacrum.  The  body  of  the  child  will  be  observed  to  follow  this  move- 
ment, so  that  its  back  is  turned  toward  the  mother's  abdomen,  its  ante- 
rior surface  to  the  perineum.  The  nape  of  the  neck  now  becomes  firmly 
fixed  under  the  arch  of  the  pubes ;  the  pains  act  chiefly  on  the  anterior 
portion  of  the  head,  and  cause  it  to  sweep  over  the  perineum,  the 
chin  being  first  born,  then  the  mouth  and  forehead,  and  lastly  the 
occiput.  .  ^  , 

Sacro-posterior  Positions. — It  is  needless  to  describe  the  differences  ^^  ^'^ 
between  the  mechanism  of  the  second  and  first  positions,  which  the  stu-  Zm:.^,  i-^ 
dent,  who  has  mastered  the  subject  of  vertex  presentations,  will  readily    __— L-,^ 
understand.     It  is  necessary,  however,  to  say  a  few  words  as  to  sacro- 
posterior positions,  choosing  for  that  purpose  the  third,  which  is  the  more 
common  of  the  two.     This  is  exactly  the  opposite  of  the  first  position. 
The  sacrum  of  the  child  points  to  the  right  sacro-iliac  synchondrosis  ;  its 
abdomen  looks  forward  and  to  the  left  side  of  the  mother.     The  trans- 
verse diameter  of  the  child's  pelvis  lies  in  the  lefl  oblique  diameter,  the 
right  hip  being  anterior.     The  birth  of  the  body  generally  takes  place 
exactly  in  the  way  that  has  been  already  described,  the  right  hip  being 
toAvard  the  pubes.  /         , 

As  the  head  descends  into  the  pelvis  the  occiput  most_usually  rotates  Y^^i.^^u^ 
along  its  right  side — the  rotation  having  been  often  already  partially  ^ 
effected  when  that  of  the  hips  had  been  made — until  it  comes  to  rest 
behind  the  pubes,  the  face  passing  backward  along  the  left  side  of  the 
pelvis  into  the  hollow  of  the  sacrum.  This  change  corresponds  exactly 
to  the  anterior  rotation  of  the  occiput  in  occipito-posterior  positions,  and 
is  the  natural  and  favorable  termination. 

Sometimes,  forward  rotation  does  not  take  place,  and  the  occiput  then 
turns  backward  into  the  hollow  of  the  sacrum.  What  then  generally 
occurs  is,  that  the  pains  continue,  for  the  reason  already  mentioned,  to 
depress  the  chin  and  produce  strong  flexion  of  the  face  on  the  sternum, 
the  occiput  becoming  fixed  on  the  anterior  border  of  the  perineum.  The 
pains  continuing  to  act  chiefly  on  the  anterior  part  of  the  head,  the  face 
is  born  first  behind  the  pubes,  the  occiput  only  slipping  over  the  per- 
ineum after  the  forehead  has  been  expelled. 

Second  Mode  in  which  such  Cases  occasionally  End. — A  second  mode 
of  termination  of  such  positions  is  mentioned  in  most  works  on  the 
authority  of  one  or  two  recorded  eases ;  but,  although  mechanically 
possible,  it  is  certainly  an  event  of  extreme  rarity.  The  chin,  instead 
of  being  flexed  on  the  sternum,  is  greatly  extended,  so  that  the  face  of 
the  child  looks  upward  toward  the  pelvic  brim.  The  child  then  u-w-iw 
hitch(;s  over  the  up])er  edge  of  the  pul)es,  and  becomes  fixed  there,  while 
the  force  of  the  uterine  contractions  is  exjH'iidcd  on  tlie  posterior  i)art  of 
tlie  head,  whi(!h  desc(!nds  througli  th(!  pelvis,  distending  the  pci'ineum, 
and  is  born  first,  the  fiice  subsequently  fijllowing. 

Meclianism  of  Feet  Presentations. — The  mechanism  of  the  delivery 
of  the  body  and  head  in  cases  in  which  the  feet  originally  present  does 

20 


306  LABOR. 

not  differ,  in  any  important  respect,  from  that  which  has  been  ah'eady 
described,  and  requires  no  separate  notice. 

Treatment. — From  what  has  been  said  of  the  natural  mechanism,  it  is 
evident  that  one  of  the  most  fruitful  causes  of  difficulty  and  complication 
is  undue  interference  on  the  part  of  the  practitioner.  It  is,  no  doubt, 
tempting  to  use  traction  on  the  partially-born  trunk  in  the  hope  of 
expediting  delivery,  but  when  it  is  remembered  that  this  is  almost 
certain  to  produce  extension  of  the  arms  above  the  head,  and  subse- 
quently extension  of  the  occiput  on  the  spine,  both  of  -which  seriously 
increase  the  difficulty  of  delivery,  the  necessity  of  leaving  the  case  as 
much  as  possible  to  nature  will  be  apparent. 

Having  once,  therefore,  determined  the  existence  of  a  pelvic  presenta- 
tion, nothing  more  should  be  done  until  the  birth  of  the  breech.  The 
membranes  should  be  even  more  carefully  prevented  from  prematurelv 
rupturing  than  in  vertex  presentations,  since  they  serve  to  dilate  the 
genital  passages  better  than  the  presenting  part.  Hence  they  should  be 
preserved  intact,  if  possible,  until  they  reach  the  floor  of  the  pelvis, 
instead  of  being  punctured  as  soon  as  the  os  is  fully  dilated.  The 
breech  when  born  should  be  received  and  supported  in  the  palm  of  the 
hand. 

Danger  to  Child. — When  the  body  is  expelled  as  far  as  the  umbilicus 
the  dangers  to  the  child  commence,  for  now  the  cord  is  apt  to  be  j^ressed 
between  the  body  of  the  child  and  the  pelvic  walls.  To  obviate  this 
risk  as  much  as  possible,  a  loop  of  the  cord  should  be  pulled  down  and 
carried  to  that  part  of  the  pelvis  where  there  is  most  room,  which  will 
generally  be  opposite  one  or  the  other  sacro-iliac  synchondrosis.  As  long 
as  the  cord  is  freely  pulsating  we  may  be  satisfied  that  the  life  of  the 
child  is  not  gravely  imperilled,  although  delay  is  fraught  with  danger 
from  other  sources  which  have  been  already  indicated.  In  most  cases 
the  arms  now  slip  out,  but  it  may  happen,  even  without  any  fault  on  the 
part  of  the  accoucheur,  that  they  are  extended  above  the  head ;  and  it  is 
of  great  importance  that  we  should  be  thoroughly  acquainted  ^vitli  the 
best  means  of  liberating  them  from  their  abnormal  position. 

Management  ivhen  the  Arms  are  Extended  above  the  Head. — They  must, 
of  course,  never  be  drawn  directly  downward,  or  the  almost  certain  result 
would  be  fracture  of  the  fragile  bones.  We  should  endeavor  to  make 
the  arm  sweep  over  the  face  and  chest  of  the  child,  so  that  the  natural 
movements  of  its  joints  should  not  be  opposed.  If  the  shoulders  be 
within  easy  reach,  the  finger  of  the  accoucheur  should  be  slipped  over 
that  which  is  posterior — because  there  is  likely  to  be  more  space  for  this 
manoeuvre  toward  the  sacrum — and  gently  carried  dowuAvard  toward 
the  elbow,  which  is  clraAvn  over  the  face,  and  then  onward,  so  as  to 
liberate  the  forearm.  The  same  manoeuvre  should  then  be  applied  to 
the  opposite  arm.  It  may  be  that  the  shoulders  are  not  easily  reached, 
and  then  they  may  be  depressed  by  altering  the  position  of  the  child's 
body.  If  this  be  carried  well  up  to  the  mother's  abdomen,  the  posterior 
shoulder  will  be  brought  lower  down  ;  and,  by  reversing  this  procedure 
and  carrying  the  body  back  over  the  perineum,  the  anterior  shoulder 
may  be  similarly  depressed.  It  is  only  very  exceptionally,  however, 
that  these  expedients  are  required. 


PELVIC  PRESENTATIONS. 


307 


Birth  of  the  Head. — The  arms  being  extracted,  some  degree  of  artifi- 
cial assistance  is  at  this  time  ahnost  always  required.  If  there  be  much 
delay  the  child  will  almost  certainly  perish.  Attempts  have  been  made, 
in  cases  in  which  delivery  of  the  head  could  not  be  rapidly  effected,  to 
establish  pulmonary  respiration  by  passing  one  or  two  fingers  into  the 
vagina,  so  as  to  press  it  back  and  admit  air  to  the  child's  mouth,  or  by 
passing  a  catheter  or  tube  into  the  mouth.  Neither  of  these  expedients 
is  reliable,  and  we  should  rather  seek  to  aid  nature  in  completing  the 
birth  of  the  head  as  rapidly  as  possible.  The  first  thing  to  do,  supposing  i 
the  face  to  have  rotated  into  the  cavity  of  the  sacrum,  is  to  carry  the 
body  of  the  child  well  up  toward  the  pubes  and  abdomen  of  the  mother 
without  applying  any  traction,  for  fear  of  interfering  with  the  all-j 
important  flexion  of  the  chin  on  the  sternum.  If  now  the  patient  bear 
down  strongly,  the  natural  powers  may  be  sufficient  to  complete  delivery. ' 
If  there  be  any  delay,  traction  must  be  resorted  to,  and  we  must  endeavor 
to  apply  it  in  such  way  as  to  ensure  flexion.  For  this  purpose,  while 
the  body  of  the  child  is  grasped  by  the  left  hand  and  drawn  upward 
toward  the  mother's  abdomen,  the  index  and  middle  fingers  of  the  right : 
hand  are  placed  on  the  back  of  the  child's  neck,  so  that  their  tips  press 
on  either  side  of  the  base  of  the  occiput  and  push  the  head  into  a  state  ^ 
of  flexion.  In  most  works  we  are  advised  to  pass  the  index  and  middle 
fingers  of  the  left  hand  at  the  same  time  over  the  child's  face,  so  as  to 
depress  the  superior  maxilla.  Dr.  Barnes  insists  that  this  is  quite 
unnecessary,  and  that  extraction  in  the  manner  indicated,  by  pressure 
on  the  occiput,  is  quite  sufficient.  Should  it  not  prove  so,  flexion  of  the 
chin  may  be  very  eflectually  assisted  by  downward  pressure  on  the  fore- 
head through  the  rectum.  One  or  two  fingers  of  the  left  hand  can 
readily  be  inserted  into  the  bowel,  and  the  expulsion  of  the  head  is  thus 
materially  facilitated. 

Value  of  Pressure  through  the  Abdomen. — By  far  the  most  poAverful 
aid,  however,  in  hastening  delivery  of  the  head,  should  delay  occur,  is 
pressure  from  above.  This  has  been,  strangely  enough,  almost  altogether 
omitted  by  writers  on  the  subject.  It  has  been  strongly  recommended 
by  Professor  Penrose,  and  there  can  be  no  question  of  its  utility.  Indeed, 
as  the  uterus  contracts  tightly  round  the  head,  uterine  expression  can  be 
applied  almost  directly  to  the  head  itself,  and  without  any  fear  of 
deranging  its  proper  relation  to  the  maternal  passages.  It  is  very 
seldom,  indeed,  that  a  judicious  combination  of  traction  on  the  part  of 
the  accoucheur,  with  firm  pressure  through  the  abdomen  applied  by  an 
assistant,  Avill  fail  in  effecting  delivery  of  the  head  before  the  delay  has 
had  time  to  prove  injurious  to  the  child. 

Application  of  the  Forceps  to  the  After-coming  Head. — Many  accou- 
cheurs— among  others  Meigs  and  Rigby — advocate  the  application  of 
the  forceps  when  there  is  delay  in  the  birth  of  the  after-coming  head. 
If  the  delay  be  due  to  want  of  expulsive  force  in  a  pelvis  of  normal  size, 
manual  extraction,  in  the  manner  just  described,  will  be  found  to  be 
sufficient  in  almost  every  case,  and  preferable,  as  being  more  rai)id, 
easier  of  execution,  and  safer  to  the  child.  The  fi)rcci)S  may  be  quite 
proj)erly  tried  if  other  means  have  fiu'led,  esp(!cially  if  there  be  some 
disproportion  between  the  size  of  the  head  and  the  pelvis. 


308  LABOR. 

Management  of  f>acro-poderior  Positions. — Difficulties  in  delivery  may 
also  occur  in  sacro-posterior  i)Ositions.  Up  to  the  time  of  the  birth  of 
the  head  the  labor  usually  progresses  as  readily  as  in  saero-anterior  posi- 
tions. If  the  forward  rotation  of  the  hips  do  not  take  place,  much 
subsequent  difficulty  may  be  prevented  by  gently  favoring  it  by  traction 
a})plied  to  the  breech  during  the  pains,  the  finger  being  passed  for  this 
purpose  into  the  fold  of  the  groin. 

It  is  after  the  birth  of  the  shoulders  that  the  absence  of  rotation  is 
most  likely  to  prove  troublesome.  It  has  been  recommended  that  the 
body  should  then  be  grasped,  in  the  interval  between  the  pains,  and 
twisted  round  so  as  to  bring  the  occiput  forward.  It  is  by  no  means 
certain,  however,  that  the  head  would  follow  the  movement  imparted  to 
the  body,  and  there  must  be  a  serious  danger  of  giving  a  fatal  twist  of 
the  neck  by  such  a  manoeuvre.  The  better  plan  is  to  direct  the  face 
backward  toward  the  cavity  of  the  sacrum,  by  pressing  on  the  anterior 
temple  during  the  continuance  of  a  pain.  In  this  way  the  proper  rota- 
tion will  generally  be  effected  without  much  difficulty,  and  the  case  will 
terminate  in  the  usual  way. 

3Ianagement  of  Oases  in  which  Forward  Rotation  does  not  Occur. — If 
rotation  of  the  occiput  forward  do  not  occur,  it  is  necessary  for  the  prac- 
titioner to  bear  in  mind  the  natural  mechanism  of  delivery  under  such 
[circumstances.     In  the  majority  of  cases  the  proper  plan  is  to  favor 
'  flexion  of  the  chin  by  upward  pressure  on  the  occiput,  and  to  exert  trac- 
Ition  directly  backward,  remembering  that  the  nape  of  the  neck  should 
/be  fixed  against  the  anterior  margin  of  the  perineum.     If  this  be  not 
remembered,  and  traction  be  made  in  the  axis  of  the  pelvic  outlet,  the 
I  delivery  of  the  head  will  be  seriously  impeded.     In  the  rare  cases  in 
\  which  the  head  becomes  extended  and  the  chin  hitches  on  the  upper 
I  margin  of  the  pubis,  traction  directly  forward  and  upward  may  be 
required  to  deliver  the  head ;  but  before  resorting  to  it  care  should  be 
I  taken  to  ascertain  that  backward  extension  of  the  head  has  really  taken 
place. 

Management  of  Impacted  Breech  Presentations. — It  remains  foi'  us  to 
consider  the  measures  which  may  be  adopted  in  those  very  troublesome 
cases  in  which  the  breech  refuses  to  descend  and  becomes  impacted  in 
the  pelvic  cavity,  either  from  uterine  inertia  or  from  disproportion 
between  the  breech  and  the  pelvis.  Here,  unfortunately,  the  peculiar 
shape  of  the  presenting  part,  which  is  unadapted  for  the  application  of 
the  forceps,  renders  such  cases  very  difficult  to  manage. 

Two  measures  have  been  chiefly  employed ;  1st,  bringing  down  one 
or  both  feet,  so  as  to  break  up  the  presenting  part>  and  convert  it  into  a 
I  footling  case ;  2d,  traction  on  the  breech,  either  by  the  fingers,  a  blunt 
'  hook,  or  fillet  passed  over  the  groin. 

1  Bringing  Down  a  Foot. — Barnes  insists  on  the  superiority  of  the 
former  plan,  and  there  can  be  no  question  that,  if  a  foot  can  be  got 
down,  the  accoucheur  has  a  complete  control  over  the  progress  of  the 
labor  which  he  can  gain  in  no  other  way.  If  the  breech  be  arrested  at 
6r  near  the  brim,  there  will  generally  be  no  great  difficulty  in  effecting 
the  desired  object.  It  will  be  necessary  to  give  chloroform  to  the  extent 
of  complete  anaesthesia,  and  to  pass  the  hand  over  the  child's  abdomen 


PELVIC  PRESENTATIONS.  309 

in  the  same  manner  and  with  the  same  precautions  as  in  performing 
podalic  version  until  a  foot  is  reached,  which  is  seized  and  pulled  down. 
If  the  feet  be  placed  in  the  usual  way  close  to  the  buttocks,  no  great 
difficulty  is  likely  to  be  experienced.  If,  however,  the  legs  be  extended 
on  the  abdomen,  it  will  be  necessary  to  introduce  the  hand  and  arm  very 
deeply,  even  up  to  the  fundus  of  the  uterus — a  procedure  which  is 
always  difficult,  and  which  may  be  very  hazardous.  Nor  do  I  think 
that  the  attempt  to  bring  down  the  feet  can  be  safe  when  the  breech  is 
low  down  and  fixed  in  the  pelvic  cavity.  A  certain  amount  of  repres- 
sion of  the  breech  is  possible,  but  it  is  evident  that  this  cannot  be  safely 
attempted  when  the  breech  is  at  all  low  down. 

Traction  on  the  Groin. — Under  such  circumstances  traction  is  our 
only  resource,  and  this  is  always  difficult  and  often  unsatisfactory.  Of 
all  contrivances  for  this  purpose,  none  is  better  than  the  hand  of  the 
accoucheur.  The  index  finger  can  generally  be  slipped  over  the  groin 
without  difficulty,  and  traction  can  be  applied  during  the  pains.  Fail- 
ing this  or  when  it  proves  insufficient,  an  attempt  should  be  made  to 
pass  a  fillet  over  the  groins.  A  soft  silk  handkerchief  or  a  skein  of 
worsted  answers  best,  but  it  is  by  no  means  easy  to  apply.  The  sim- 
plest plan,  and  one  which  is  far  better  than  the  expensive  instruments 
contrived  for  the  purpose,  is  to  take  a  stout  piece  of  copper  wire  and 
bend  it  double  into  the  form  of  a  hook.  The  extremity  of  this  can  gen- 
erally be  guided  over  the  hips,  and  through  its  looped  end  the  fillet  is 
passed.  The  wire  is  now  withdrawn,  and  carries  the  fillet  over  the 
groins.  I  have  found  this  simple  contrivance,  which  can  be  manufac- 
tured in  a  few  moments,  very  useful,  and  by  means  of  such  a  fillet  very 
considerable  tractive  force  can  be  employed.  The  use  of  a  soft  fillet  is 
in  every  way  preferable  to  the  blunt  hook  which  is  contained  in  most 
obstetric  bags.  A  hard  instrument  of  this  kind  is  quite  as  difficult  to 
apply,  and  any  strong  traction  employed  by  it  is  almost  certain  to  seri- 
ously injure  the  delicate  foetal  structures  over  Avhich  it  is  placed.  As 
an  auxiliary  the  employment  of  uterine  expression  should  not  be  forgot- 
ten, since  it  may  give  material  aid  when  the  difficulty  is  only  due  to 
uterine  inertia.  After  a  difficult  breech  labor  is  completed  the  child 
should  be  carefully  examined  to  see  that  the  bones  of  the  thighs  and 
arms  have  not  been  injured.  Fractures  of  the  thigh  are  far  from  uncom- 
mon in  such  cases,  and  the  soft  bones  of  the  newly-born  child  will  read- 
ily and  rapidly  unite  if  placed  at  once  in  proper  splints. 

Embryotomy. — Failing  all  endeavors  to  deliver  by  these  expedients, 
there  is  no  resource  left  but  to  break  up  the  presenting  part  by  scissors 
or  by  craniotomy  instruments ;  but,  fortunately,  so  extreme  a  measure 
is  but  rarely  necessary. 


310  LABOR. 


CHAPTER  VI. 

PRESENTATIONS  OF  THE   FACE. 

Presentations  of  the  face  are  by  no  means  rare,  and,  although  in 
the  great  majority  of  cases  they  terminate  satisfactorily  by  the  unassisted 
powers  of  nature,  yet  every  now  and  again  they  give  rise  to  much  diffi- 
culty, and  then  they  may  be  justly  said  to  be  amongst  the  most  formid- 
able of  obstetric  complications.  It  is  therefore  essential  that  the  prac- 
titioner should  thoroughly  understand  the  natural  history  of  this  variety 
of  presentation,  with  the  view  of  enabling  him  to  intervene  with  the 
best  prospect  of  success. 

Erroneous  Views  Formerly  Held. — The  older  accoucheurs  had  very 
erroneous  views  as  to  the  mechanism  and  treatment  of  these  cases,  most 
of  them  believing  that  delivery  was  impossible  by  the  natural  efforts, 
and  that  it  was  necessary  to  intervene  by  version  in  order  to  effect  deliv- 
ery. Smellie  recognized  the  fact  that  spontaneous  delivery  is  possible, 
and  that  the  chin  turns  forward  and  under  the  pubes ;  but  it  was  not 
until  long  after  his  time,  and  chiefly  after  the  appearance  of  Mme.  La 
Chapelle's  essay  on  the  subject,  that  the  fact  that  most  cases  could  be 
naturally  delivered  was  fully  admitted  and  acted  upon. 

Frequency. — The  frec{uency  of  face  presentation  varies  curiously  in 
different  countries.  Thus,  Collins  found  that  in  the  Rotunda  Hospital 
there  M'as  only  1  case  in  497  labors,  although  Churchill  gives  1  in  249 
as  the  average  frequency  in  British  practice ;  ^^hile  in  Germany  this 
presentation  is  met  with  once  in  169  labors.  The  only  reasonable 
explanation  of  this  remarkable  difference  is,  that  the  dorsal  decubitus, 
generally  followed  abroad,  favors  the  transformation  of  vertex  presenta- 
tions into  those  of  the  face. 

The  mode  in  M'hich  this  change  is  effected — for  it  can  hardly  be 
doubted  that  in  the  large  majority  of  cases  face  presentation  is  due  to  a 
backward  displacement  of  the  occiput  after  labor  has  actually  com- 
menced, but  before  the  head  has  engaged  in  the  brim — has  been  made 
the  subject  of  various  explanations. 

Mode  in  ichich  Face  Presentations  are  Produced. — It  has  generally  been 
supposed  that  the  change  is  induced  by  a  hitching  of  the  occiput  on  the 
brim  of  the  pelvis,  so  as  to  produce  extension  of  the  head  and  descent 
of  the  face,  the  occurrence  being  favored  by  the  oblique  position  of  the 
uterus  so  frequently  met  with  in  pregnancy.  Hecker  attaches  consider- 
able importance  to  a  peculiarity  in  the  shape  of  the  foetal  head  generally 
observed  in  face  presentations,  the  cranium  having  the  dolicho-cephalous 
form,  prominent  posteriorly,  with  the  occiput  projecting,  wliich  has  the 
effect  of  increasing  the  length  of  the  posterior  cranial  lever  arm,  and 
facilitating  extension  when  circumstances  favoring  it  are  in  action.  Dr. 
Duncan  ^  thinks  that  uterine  obliquity  has  much  influence  in  the  produc- 
tion of  face  presentation,  but  in  a  different  way  to  that  above  referred 

^  Edin.  Med.  Journ.,  vol.  xv. 


PBESENTATIONS  OF  THE  FACE.  311 

to.  He  points  out  that  when  obliquity  is  very  marked  a  curve  in  the 
genital  passages  is  produced,  the  convexity  of  Avhich  is  directed  to  the 
side  toward  which  the  uterus  is  deflected.  When  uterine  contraction 
commences  the  foetus  is  propelled  downward,  and  the  part  corresponding 
to  the  concavity  of  the  curve  is  acted  on  to  the  greatest  advantage  by  the 
propelling  force,  and  tends  to  descend.  Should  the  occiput  happen  to 
lie  in  the  convexity  of  the  curve  so  formed,  the  tendency  will  be  for  the 
forehead  to  descend.  In  the  majority  of  cases  its  descent  will  be  pre- 
vented by  the  increased  resistance  it  meets  with,  in  consequence  of  the 
greater  length  of  the  anterior  cranial  lever  arm ;  but  if  the  uterine 
obliquity  be  extreme  this  may  be  counterbalanced,  and  a  face  presenta- 
tion ensues.  The  influence  of  this  obliquity  is  corroborated  by  the 
observation  of  Baudelocque,  that  the  occiput  in  face  presentations  almost 
invariably  corresponds  to  the  side  of  the  uterine  obliquity.  A  further 
corroboration  is  afforded  by  the  fact  that  in  face  presentation  the  occiput 
is  much  more  frequently  directed  to  the  right  than  to  the  left,  while  right 
lateral  obliquity  of  the  uterus  is  also  much  more  common. 

These  theories  assume  that  face  presentations  are  produced  during 
labor.  In  a  few  cases  they  certainly  exist  before  labor  has  commenced. 
It  is  possible,  however,  as  we  know  that  uterine  contractions  exist  inde- 
pendently of  actual  labor,  that  similar  causes  may  also  be  in  operation, 
although  less  distinctly,  before  the  commencement  of  labor. 

Diagnosis. — The  diagnosis  is  often  a  matter  of  considerable  difficulty 
at  an  early  period  of  labor,  before  the  os  is  fully  dilated  and  the  mem- 
branes ruptured,  and  when  the  face  has  not  entered  the  pelvic  cavity. 
The  finger  then  impinges  on  the  rounded  mass  of  the  forehead,  which 
may  very  readily  be  mistaken  for  the  vertex.  At  this  stage  the  diag- 
nosis may  be  facilitated  by  abdominal  palpation  in  the  way  suggested  by 
Hecker.  If  the  face  is  presenting  at  the  brim,  palpation  will  enable  us 
to  distinguish  a  hard,  firm,  and  rounded  body  immediately  above  the 
pubes,  which  is  the  forehead  and  sinciput ;  on  the  other  side  will  be  felt 
an  indistinct,  soft  substance,  corresponding  to  the  thorax  and  neck. 
When  labor  is  advanced  and  the  head  has  somewhat  descended,  or  when 
the  membranes  are  ruptured,  we  should  be  able  to  make  out  the  nature  , 
of  the  presentation  with  certainty.  The  diagnostic  marks  to  be  relied  j  ^^'' 
on  are  the  edges  of  the  orbits,  the  prominence  of  the  nose,  the  nostrils 
(their  orifices  showing  to  which  part  of  the  pelvis  the  chin  is  turned), 
and  the  cavity  of  the  mouth  with  the  alveolar  ridges.  If  these  be  made 
out  satisfactorily,  no  mistake  should  occur.  The  most  difficult  cases  are 
those  in  which  the  face  has  been  a  considerable  time  in  the  pelvis. 
Under  such  circumstances  the  cheeks  become  greatly  swollen  and  pressed 
togetliei',  so  as  to  reseml)le>  the  nates.  The  nose  might  then  be  mistaken 
for  tiic  genital  organs,  and  the  mouth  for  the  anus.  The  orbits,  how- 
ever, and  the  alveolar  ridges  resemble  nothing  in  the  breech,  and  should 
be  sufficient  to  prevent  error.  Considerable  care  should  be  taken  not  to 
examine  too  frcfiuently  and  roughly,  otlierwise  sei-ious  injury  to  the  deli- 
cate structures  of  the  face  nn'glit  be  inflicted.  When  once  the  ])rcsenta- 
tion  has  been  satisfactorily  diagnosed,  examinations  should  be  made  as 
seldom  as  possible,  and  only  to  assure  ourselves  that  the  case  is  progress- 
ing satisfactorily. 


312  LABOR. 

3fechanism. — If  we  regard  face  presentations,  as  we  are  fully  justified 
in  doing,  as  being  generally  produced  by  the  extension  of  the  occiput  in 
what  were  originally  vertex  presentations,  we  can  readily  understand 
that  the  position  of  the  face  in  relation  to  the  pelvis  must  correspond 
to  that  of  the  vertex.  This  is,  in  fact,  what  is  found  to  be  the  case,  the 
forehead  occupying  the  position  in  which  the  occiput  ^^'ould  have  been 
placed  had  extension  not  occurred. 

The  Positions  of  the  Face  correspond  to  those  of  the  Vertex. — The  face, 
then,  like  the  head,  may  be  placed  with  its  long  diameter  corresponding 
to  almost  any  of  the  diameters  of  the  brim,  but  most  generally  it  lies 
either  in  the  transverse  diameter  or  between  this  and  the  oblique,  M'hile, 
as  it  descends  in  the  pelvis,  it  more  generally  occupies  one  or  other  of 
the  oblique  diameters.  It  is  common  in  obstetric  works  to  describe  two 
principal  varieties  of  face  presentation — viz.  the  right  and  left  mento- 
iliac — according  as  the  chin  is  turned  to  one  or  other  side  of  the  pelvis. 
It  is  better,  however,  to  classify  the  positions  in  accordance  with  the  part 
of  the  pelvis  to  which  the  chin  points.  We  may  therefore  describe  four 
positions  of  the  face,  each  being  analogous  to  one  of  the  ordinary  vertex 
presentations,  of  which  it  is  the  transformation  : 

First  Position, — The  chin  points  to  the  right  sacro-iliac  synchondro- 
sis, the  forehead  to  the  left  foramen  ovale,  and  the  long  diameter  of  the 
face  lies  in  the  right  oblique  diameter  of  the  pelvis.  This  corresponds 
to  the  first  position  of  the  vertex,  and,  as  in  that,  the  back  of  the  child 
lies  to  the  left  side  of  the  mother. 

Second  Position. — The  chin  points  to  the  left  sacro-iliac  synchondro- 
sis, the  forehead  to  the  right  foramen  ovale,  and  the  long  diameter  of 
the  face  lies  in  the  left  oblique  diameter  of  the  pelvis.  This  is  the  con- 
version of  the  second  vertex  position. 

Third  Position. — The  forehead  (Fig.  112)  points  to  the  right  sacro- 
iliac synchondrosis,  the  chin  to  the  left  foramen  ovale,  and  the  long 
diameter  of  the  face  lies  in  the  right  oblique  diameter  of  the  pelvis. 
This  is  the  conversion  of  the  third  vertex  position. 

Fourth  Position. — The  forehead  points  to  the  left  sacro-iliac  synchon- 
drosis, the  chin  to  the  right  foramen  ovale,  and  the  long  diameter  of  the 
face  lies  in  the  left  oblique  diameter  of  the  pelvis.  This  is  the  conver- 
sion of  the  fourth  vertex  position. 

The  Relative  Frequency  of  these  Positions. — The  relative  frequency  of 
these  presentations  is  not  yet  positively  ascertained.  It  is  certain  that 
there  is  not  the  preponderance  of  first  facial  that  there  is  of  first  vertex 
positions,  and  this  may  no  doubt  be  explained  by  the  supposition  that 
an  unusual  vertex  position  may  of  itself  facilitate  the  transformation 
into  a  face  presentation.  Winckel  concludes  that,  cceteris  paribus,  a  face 
presentation  is  more  readily  produced  when  the  back  of  the  child  lies  to 
the  right  than  when  it  lies  to  the  left  side  of  the  mother,  the  reason  for 
this  being  probably  the  frequency  of  right  lateral  obliquity  of  the  uterus. 
We  shall  presently  see  that,  with  very  rare  exceptions,  it  is  absolutely 
essential  that  the  chin  should  rotate  forward  under  the  pubes  before 
delivery  can  be  accomplished ;  and  therefore  we  may  regard  the  third 
and  fourth  face  positions,  in  which  the  chin  from  the  first  points  ante- 
riorly, as  more  favorable  than  the  first  and  second. 


PRESENTATIONS  OF  THE  FACE. 


313 


The  mechanism  of  delivery  in  face  is  practically  the  same  as  in  vertex 
presentations  ;  and  we  shall  have  no  difficulty  in  understanding  it  if  we 
bear  in  mind  that  in  face  cases  the  forehead  tates  the  place  of,  and  rep- 
resents the  occiput  in,  vertex  presentations.  For  the  purpose  of  descrip- 
tion we  will  take  the  first  position  of  the  face. 

Description  of  Delivery  in  the  First  Position  of  the  Face. — 1.  Exten- 
sion.— The  first  step  consists  in  the  extension  of  the  head,  which  is 
effected  by  the  uterine  contractions  as  soon  as  the  membranes  are  rup- 
tured. By  this  the  occiput  is  still  more  completely  pressed  back  on  the 
nape  of  the  neck,  and  the  fronto-mental,  rather  than  the  mento-breg- 


FiG.  112. 


\ 


Third  Position  in  Face  Presentations. 

matic,  diameter  is  placed  in  relation  to  the  pelvic  brim.  This  corre- 
sponds to  the  stage  of  flexion  in  vertex  presentations. 

The  chin  descends  below  the  forehead  from  precisely  the  same  cause 
as  the  occiput  in  vertex  presentations.  On  account  of  the  extended  posi- 
tion of  the  head  the  presenting  face  is  divided  into  portions  of  unequal 
length  in  relation  to  the  vertebral  column,  through  which  the  force  is  ap- 
plied, the  longer  lever. arm  being  toward  the  forehead.  The  resistance 
is,  tlierefijre,  greatest  toward  the  forehead,  which  remains  behind  wJiile 
the  chin  descends. 

2.  Descent. — As  the  pains  continue,  the  head  (the  chin  being  still  in 
advance)  is  propelled  through  the  pelvis.  It  is  generally  said  that  the 
face  cannot  descend,  like  the  occiput,  down  to  the  floor  of  the  pelvis, 
its  descent  being  limited  by  the  length  of  the  neck.  There  is  here, 
however,  an  obvious  misa))])reliension.  Tlic  neck  from  the  chin  to  the 
sternum,  when  tlu;  }i(;ad  is  forcibly  cxtend(!d,  measures  from  3j^  to  4 
inclies — a  lengtli  tliat  is  more  tlian  sufficient  to  admit  of  the  face  des(;end- 
ing  to  the  lower  pelvic  .strait.  As  a  matter  of  fact,  the  (^hin  is  frequently 
ob.served  in  mento-posterior  positions  to  descend  so  far  that  it  is  appar- 


^-^xUi^ 


314 


LABOR. 


ently  endeavoring  to  pass  the  jDerineum  before  rotation  occurs.  At  the 
brim  the  two  sides  of  the  face  are  on  a  level,  but  as  labor  advances  the 
right  cheek  descends  somewhat,  the  caput  succedaneum  forms  on  the 
malar  bone,  and,  if  a  secondary  caput  succedaneum  form,  on  the  cheek. 
I  3.  Rotation  is  by  far  the  most  important  point  in  the  mechanism  of 
!  face  presentations ;  for  unless  it  occurs,  delivery  with  a  full-sized  head 
and  an  average  pelvis  is  practically  impossible.  There  are,  no  doubt, 
exceptions  to  this  rule,  which  must  be  separately  considered,  but  it  is 
certain  that  the  absence  of  rotation  is  always  a  grave  and  formidable 
complication  of  face  presentation.  Fortunately,  it  is  only  very  rarely 
that  this  is  not  effected.  The  mechanical  causes  are  precisely  those  which 
produce  rotation  of  the  occiput  for^vard  in  vertex  presentations.  As  it 
IS  accomplished  the  chin  passes  under  the  arch  of  the  pubes,  and  the 
occiput  rotates  into  the  hollow  of  the  sacrum  (Fig.  113);  and  then 
commences — 

4.  Flexion,  a  movement  which  corresponds  to  extension  in  vertex 
cases.     The  chin  passes  as  far  as  it  can  under  the  pubic  arch,  and  there 

Fig.  113. 


Rotation  Forward  of  Chin. 

becomes  fixed.  The  uterine  force  is  now  expended  on  the  occiput,  which 
revolves,  as  it  were,  on  its  transverse  axis  (Fig.  114),  the  under  surface 
of  the  chin  resting  on  the  pubes  as  a  fixed  point.  This  movement  goes 
on  until,  at  last,  the  face  and  occiput  sweep  over  the  distended  perineum. 

5.  External  rotation  is  precisely  similar  to  that  which  takes  place  in 
head  presentations,  and,  like  it,  depends  on  the  movements  imparted  to 
the  shoulders. 

Mento-posterior  Positions  in  which  Rotation  does  Not  take  Place. — Such 
is  the  natural  course  of  delivery  in  the  vast  majority  of  cases ;  but  in 
order  fully  to  understand  the  subject  it  is  necessary  to  study  those  rare 
cases  in  which  the  chin  points  backward  and  forward  rotation  does  not 


PRESENTATIONS  OF  THE  FACE. 


315 


occur.      These  may  be  taken  to  correspond  to  the  occipito-posterior 
positions,  in  which  the  face  is  born  looking  to  the  pubes ;    but,  unlike 


Fig.  114. 


Passage  of  the  Head  through  the  External  Parts  in  Face  Presentation. 

them,  it  is  only  very  exceptionally  that  delivery  can  be  naturally  com- 
pleted. The  reason  of  this  is  obvious,  for  the  occiput  gets  jammed 
iDehind  the  pubes,  and  there  is  no  space  for  the  fronto-mental  diameter 

Fig.  115. 


Illustrating  the  PoHition  of  the  Ilfart  when  Forward  Rotation  of  the  Chin  does  Not  take  Place. 

to  pass  th<;  antero-postcrior  diameter  of  the  outlet  (Fig.  1 15).     Cases  arc 
indeed  recorded  in  which  delivery  has  been  effected  with  tlie  chin  looking 


316  LABOR. 

posteriorly,  but  there  is  every  reason  to  believe  that  this  can  only  happen 
when  the  head  is  either  unusually  small  or  the  pelvis  unusually  large. 
In  such  cases  the  forehead  is  pressed  down  until  a  portion  appears  at 
the  ostium  vagiuEe,  when  it  becomes  firmly  fixed  behind  the  pubes,  and 
the  chin,  after  many  efforts,  slijxs  over  the  perineum.  When  this  is 
effected  flexion  occurs,  and  the  occiputf  is  expelled  without  difficulty. 
The  forehead  is  probably  always  on  a  lower  level  than  the  chin. 

Dr.  Hicks  ^  has  published  a  paper  in  which  he  attempts  to  show  that 
this  termination  of  face  presentations  is  not  so  rare  as  is  generally  sup- 
posed, and  he  gives  a  single  instance  in  which  he  effected  delivery  with 
the  forceps ;  but  he  practically  admits  that  special  conditions  are  neces- 
sary, such  as  the  "  antero-posterior  diameter  of  the  outlet  particularly 
ample"  and  a  diminished  size  of  the  head.  When  delivery  is  effected 
it  is  probable,  as  Cazeaux  has  pointed  out,  that  the  face  lies  in  the  oblique 
diameter  of  the  outlet,  and  that  the  chin  depresses  the  soft  structures  at 
the  side  of  the  sacro-ischiatic  notch,  which  yield  to  the  extent  of  a  quar- 
ter of  an  inch  or  more,  and  thereby  permit  the  passage  of  the  occipito- 
mental diameter  of  the  head.  It  must,  however,  be  borne  well  in  mind 
that  spontaneous  delivery  in  mento-posterior  positions  is  the  rare  excep- 
tion, and  that,  supposing  rotation  does  not  occur — and  it  often  does  so  at 
the  last  moment — artificial  aid  in  one  form  or  another  Avill  be  almost 
certainly  required. 

/  Prognosis  of  Face  Presentations. — As  regards  the  mother,  in  the  great 
I  majority  of  cases  the  prognosis  is  favorable,  but  the  labor  is  apt  to  be 
prolonged,  and  she  is  therefore  more  exposed  to  the  risks  attending  tedi- 
ous delivery.  As  regards  the  child,  the  prognosis  is  much  mqre_unfav- 
orable  than  in  vertex  presentations.  Even  when  the  anterior  rotation 
of  the  chin  takes  place  in  the  natural  way,  it  is  estimated  that  1  out  of 
10  children  is  stillborn,  while  if  not  the  death  of  the  child  is  almost 
certain.  This  increased  infantile  mortality  is  evidently  due  to  the  serious 
amount  of  pressure  to  which  the  child  is  subjected,  and  probably  depends 
in  many  cases  on  cerebral  congestion,  produced  by  pressure  on  the  jugu- 
j  lar  veins  as  the  neck  lies  in  the  pelvic  cavity.  Even  when  the  child  is 
'  born  alive,  the  face  is  always  greatly  swollen  and  disfigured.  In  some 
cases  the  deformity  produced  in  this  way  is  excessive  and  the  features 
are  often  scarcely  recognizable.  This  disfiguration  passes  away  in  a  few 
days,  but  the  practitioner  should  be  aware  of  the  probability  of  its 
occurrence,  and  should  warn  the  friends,  or  they  might  be  unnecessarily 
alarmed,  and  possibly  might  lay  the  blame  on  him. 

Treatment. — After  what  has  l3een  said  as  to  the  mechanism  of  delivery 
in  face  presentation,  it  is  obvious  that  the  proper  course  is  to  leave  the 
case  alone,  in  the  expectation  of  the  natural  efforts  being  sufficient  to 
complete  delivery.  Fortunately,  in  the  large  majority  of  cases  this 
course  is  attended  by  a  successful  result. 

The  older  accoucheurs,  as  has  been  stated,  thought  active  interference 
absolutely  essential,  and  recommended  either  podalic  version  or  the 
attempt  to  convert  the  case  into  a  vertex  presentation  by  inserting  the 
hand  and  bringing  down  the  occiput.  The  latter  plan  was  recommended 
by  Baudelocque,  and  is  even  yet  followed  by  some  accoucheurs.    Thus,  Dr. 

^  Obst.  Ivans.,  vol.  vii. 


PRESENTATIONS  OF  THE  FACE.  317 

Hodge ^  advises  it  in  all  cases  in  which  face  presentation  is  detected  at 
the  brim ;  but,  although  it  might  not  have  been  attended  with  evil  con- 
sequences in  his  experienced  hands,  it  is  certainly  altogether  unnecessary, 
and  would  infallibly  lead  to  most  serious  results  if  generally  adopted. 
It  may,  however,  be  allowable  in  certain  cases  in  which  the  face  remains 
above  the  brim  and  refuses  to  descend  into  the  pelvic  cavity.  Even 
then  it  is  questionable  whether  podalic  version  should  not  be  pre- 
ferred, as  being  easier  of  performance,  giving,  when  once  effected,  a 
much  more  complete  control  over  delivery,  and  being  less  painful  to 
the  mother.  Version  is  certainly  preferable  to  the  application  of  the 
forceps,  which  are  introduced  with  difficulty  in  so  high  a  position  of 
the  flice,  and  do  not  take  a  secure  hold. 

Rectification  by  Abdominal  Palpation. — Schatz^  has  more  recently 
suggested  the  rectification  of  face  presentations  at  an  early  stage,  before 
the  rupture  of  the  membranes,  by  manipulation  through  the  abdomen. 
He  raises  the  foetal  body  by  pressure  on  the  shoulder  and  breast  through 
the  abdominal  wall  by  one  hand,  while  the  breech  is  raised  and  steadied 
by  the  other.  By  tliis  means  the  occiput  is  elevated,  and  then  the 
breech  is  pressed  downward,  when  head  flexion  is  produced  by  the 
resistance  of  the  pelvic  walls.  Of  this  method  I  have  had  no  practical 
experience,  but  it  obviously  requires  an  unusual  amount  of  skill  and 
practice  in  abdominal  palpation. 

Dificulties  from  Arrest  in  the  Pelvic  Cavity. — When  once  the  face  has 
descended  into  the  pelvis,  difficulties  may  arise  from  two  chief  causes — 
uterine  inertia  and  non-rotation  forward  of  the  chin. 

The  treatment  of  the  former  class  must  be  based  on  precisely  the  same 
general  principles  as  in  dealing  with  protracted  labor  in  vertex  presenta- 
tions. The  forceps  may  be  applied  with  advantage,  bearing  in  mind 
the  necessity  of  getting  the  chin  under  the  pubes,  and,  when  this  has 
been  effected,  of  directing  the  traction  forward,  so  as  to  make  the  occiput 
slowly  and  gradually  distend  and  sweep  over  the  perineum. 

Dijfficidiies  arising  from  Non-rotation  of  Chin  Fonoard. — The  second 
class  of  difficult  face  cases  are  much  more  important,  and  may  try  the 
resources  of  the  accoucheur  to  the  utmost.  Our  first  endeavor  must  be, 
if  possible,  to  secure  the  anterior  rotation  of  the  chin.  For  this  purpose 
various  manoeuvres  are  recommended.  By  some  we  are  advised  to 
introduce  the  finger  cautiously  into  the  mouth  of  the  child  and  draw 
the  chin  forward  during  a  pain  ;  by  others,  to  pass  the  finger  up  behind 
the  occiput  and  press  it  backward  during  the  pain.  Schroeder  points 
out  that  tlie  difficulty  often  depends  on  the  fact  of  the  head  not  being 
sufficiently  extended,  so  that  the  chin  is  not  on  a  lower  level  than  the 
forehead,  and  that  rotation  is  best  promoted  by  pressing  the  forehead 
uj_)ward  with  the  finger  during  a  pain,  so  as  to  cause  the  chin  to  descend. 
Penrose'^  l)elieves  that  non-rotation  is  generally  caused  by  the  want 
of  a  point  d'apptui  below,  on  account  of  the  face  being  unable  to  de- 
scend to  the  floor  of  the  pelvis,  and  that  if  this  is  supplied  rotation  will 
take  i)lace.  In  such  cases  he  applies  the  hand  or  the  blade  of  the  for- 
ceps, so  as  to  press  on  the  postericjr  cheek.     By  this  means  the  neces- 

1  Syatem  of  OhMelrics,  p.  335.  ^  ji-rJ,./.  Gyti..,  B.  v.  313. 

•''  Amer.  Supplement  to  Obst.  Journ.,  April,  1870. 


318  LABOR. 

sary  point  cVappui  is  given  ;  and  he  relates  several  interesting  cases  in 
which  this  simple  manoeuvre  was  effectual  in  rapidly  terminating  a  pre- 
viously lengthy  labor.  Any  or  all  of  these  plans  may  be  tried.  AVe 
must  bear  in  mind,  in  using  them,  that  rotation  is  often  delayed  until 
the  face  is  quite  at  the  lower  pelvic  strait,  so  that  we  need  not  too  soon 
despair  of  its  occurring.  If,  however,  in  spite  of  these  manoeuvres,  it 
do  not  take  place,  what  is  to  be  done  ?  If  the  head  be  not  too  low  down 
in  the  pelvis  to  admit  of  version,  that  would  be  the  simplest  and  most 
effectual  plan.  I  have  succeeded  in  delivering  in  this  way  when  all 
attempts  at  producing  rotation  had  failed ;  but  generally  the  face  will  be 
too  decidedly  engaged  to  render  it  possible.  An  attempt  might  be  made 
to  bring  down  the  occiput  by  the  vectis  or  by  a  fillet,  but  if  the  face  be 
in  the  pelvic  cavity  it  is  hardly  possible  for  this  plan  to  succeed.  An 
endeavor  may  be  made  to  produce  rotation  by  the  forceps ;  but  it  should 
be  remembered  that  rotation  of  the  face  mechanically  in  this  way  is  very 
difficult,  and  much  more  likely  to  be  attended  with  fatal  consequences 
to  the  child  than  when  it  is  effected  by  the  natural  efforts.  In  using 
forceps  for  this  purpose,  the  second  or  pelvic  curve  is  likely  to  prove 
injurious,  and  a  short  straight  instrument  is  to  be  preferred.  If  rotation 
be  found  to  be  impossible,  an  endeavor  may  be  made  to  draw  the  face 
downward,  so  as  to  get  the  chin  over  the  perineum  and  deliver  in  the 
mento-posterior  position  ;  but,  unless  the  child  be  small  or  the  pelvis 
very  capacious,  the  attempt  is  unlikely  to  succeed.  Finally,  if  all  these 
means  fail  there  is  no  resource  left  but  lessening  the  size  of  the  head  by 
craniotomy — a  dernier  ressort  which,  fortunately,  is  very  rarely  required. 

Brow  Presentations. — It  sometimes  happens  that  the  head  is  partially 
extended,  so  as  to  bring  the  os  frontis  into  the  brim  of  the  pelvis  and 
form  what  is  described  as  a  "  brota  presentation.''^  Should  the  head 
descend  in  this  manner,  the  difficulties,  although  not  insuperable,  are 
apt  to  be  very  great,  from  the  fact  that  the  long  cervico-frontal  diameter 
of  the  head  is  engaged  in  the  pelvic  cavity.  The  diagnosis  is  not  diffi- 
cult, for  the  OS  frontis  will  be  detected  by  its  rounded  surface,  while  the 
anterior  fontanelle  is  within  reach  in  one  direction,  the  orbit  and  root 
of  the  nose  in  another. 

Spontaneously  Converted  into  Face  or  Vertex  Presentations. — Fortu- 
nately, in  the  large  majority  of  cases  brow  presentations  are  spontane- 
ously converted  into  either  vertex  or  face  presentations,  according  as 
flexion  or  extension  of  the  head  occurs ;  and  these  must  be  regarded 
as  the  desirable  terminations  and  the  ones  to  be  favored.  For  this  pur- 
pose upward  pressure  must  be  made  on  one  or  other  extremity  of  the 
presenting  part  during  a  pain,  so  as  to  favor  flexion  or  extension  ;  or, 
if  the  parts  be  sufficiently  dilated,  an  attempt  may  be  made  to  pass  the 
hand  over  the  occiput  and  draw  it  down,  thus  performing  cephalic  ver- 
sion. The  latter  is  the  plan  recommended  by  Hodge,  who  describes  the 
operation  as  easy.  It  is  questionable,  however,  if  a  well-marked  brow 
presentation  be  distinctly  made  out  while  the  head  is  still  at  the  brim, 
whether  podalic  version  would  not  be  the  easiest  and  best  operation.  If 
the  forehead  have  descended  too  low  for  this,  and  if  the  endeavor  to 
convert  it  into  either  a  face  or  vertex  presentation  fail,  the  forceps  will 
probably  be  required.     In  such  cases  the  face  generally  turns  toward 


DIFFICULT  OCCIPITO-POSTEBIOB  POSITIONS.  319 

the  pubes,  the  superior  maxilla  becomes  fixed  behind  the  pubic  arch, 
and  the  occiput  sweeps  bver  the  perineum.  Very  great  difficulty  is 
likely  to  be  experienced,  and,  if  conversion  into  either  a  vertex  or  face 
presentation  cannot  be  eifected,  craniotomy  is  not  unlikely  to  be  required. 


CHAPTER   YII. 

DIFFICULT   OCCIPITO-POSTEEIOK  POSITIONS. 

A  FElv  words  may  be  said  in  this  place  as  to  the  management  of 
occipito-posterior  positions  of  the  head,  especially  of  those  in  which 
forward  rotation  of  the  occiput  does  not  take  place.  It  has  already  been 
pointed  out  that  in  the  large  majority  of  these  cases  the  occiput  rotates 
forward  without  any  particular  difficulty,  and  the  labor  terminates  in 
the  usual  way,  with  the  occiput  emerging  under  the  arch  of  the  pubes. 

Rotation  Forward  of  the  Occiput. — In  a  certain  number  of  cases  such 
rotation  does  not  occur,  and  difficulty  and  delay  are  apt  to  follow.  The 
proportion  of  cases  in  which  face-to-pubes  terminations  of  occipito-pos- 
terior positions  occur  has  been  variously  estimated,  and  they  are  certainly 
more  common  than  most  of  our  text-books  lead  us  to  expect.  Dr. 
Uvedale  West,^  who  studied  the  subject  with  great  care,  found  that  labor 
ended  in  this  way  in  79  out  of  2585  births,  all  these  deliveries  being 
exceptionally  difficult. 

Causes  of  Face-to-Pubes  Delivery. — He  believed  that  forward  rotation 
of  the  head  is  prevented  by  the  absence  of  flexion  of  the  chin  on  the 
sternum,  so  that  the  long  occipito-frontal,  instead  of  the  short  sub- 
occipito-bregmatic,  diameter  of  the  head  is  brought  into  contact  with  the 
pelvic  diameter ;  hence  the  occiput  is  no  longer  the  lowest  point,  and  is 
not  subjected  to  the  action  of  those  causes  which  produce  forward  rota- 
tion. Dr.  Macdonald,  who  has  written  a  thoughtful  paper  on  the  sub- 
ject,^ believes  that  the  non-rotation  forward  of  the  occiput  is  chiefly  due 
to  the  large  size  of  the  head,  in  consequence  of  which  "  the  forehead  gets 
so  wedged  into  the  pelvis  anteriorly  that  its  tendency  to  slacken  and 
rotate  forward  does  not  come  into  play."  Dr.  West's  interpretation,  which 
has  an  important  bearing  on  the  management  of  these  cases,  seems  to 
explain  most  correctly  the  non-occurrence  of  the  natural  rotation. 

The  important  question  for  us  to  decide  is,  How  can  we  best  assist  in 
the  management  of  cases  of  this  kind  when  difficulties  arise  and  labor  is 
seriously  retarded  ? 

3Iode  of  Treatment. — Dr.  West,  insisting  strongly  on  the  necessity  of 
com])lf'te  flexion  of  the  eliin  on  the  sternimi,  advises  that  this  should  l^e 
favored  by  upward  prcjssure  on  the  frontal  bone,  with  the  view  of  causing 
the  chin  to  approach  the  sternum  and  the  occiput  to  descend,  and  thus  to 
come  within  the  action  of  the  agencies  which  fiivor  rotation.     Supposing 

'  Cranial  Presentations,  p.  33.  ^  Edin.  Med.  Journ.,  Oct.,  1874. 


320  LABOR. 

the  pains  to  be  strong  and  the  fontanelle  to  be  readily  Avithin  reach,  we 
may  in  this  way  very  possibly  favor  the  d(fecent  of  the  occiput,  and 
without  injuring  the  mother  or  increasing  the  difficulties  of  the  case  in 
the  event  of  the  manoeuvre  failing.  The  beneficial  effects  of  this  simple 
expedient  are  sometimes  very  remarkable.  In  two  cases  in  Mhich  I 
recently  adopted  it  labor,  previously  delayed  for  a  length  of  time  Asithout 
any  apparent  progress,  although  the  pains  were  strong  and  effective,  was 
in  each  instance  rapidly  finished  almost  immediately  after  the  upward 
pressure  was  applied.  The  rotation  of  the  face  backward  may  at  the 
same  time  be  favored  by  pressure  on  the  pubic  side  of  the  forehead 
during  the  pains. 

Traction  on  the  Occiput. — Others  have  advised  that  the  descent  of  the 
occiput  should  be  promoted  by  downward  traction,  applied  by  the  vectis 
or  fillet.  The  latter  is  the  plan  specially  advocated  by  Hodge  -^  and  the 
fillet  certainly  finds  one  of  its  most  useful  applications  in  cases  of  this 
kind,  as  being  simpler  of  application  and  probably  more  effective  than 
the  vectis. 

Over-active  Endeavors  at  Assistance  should  be  Avoided. — Although 
any  of  these  methods  may  be  adopted,  a  word  of  caution  is  necessary 
against  prolonged  and  over-active  endeavors  at  producing  flexion,  and 
rotation  when  that  seems  delayed.  All  who  have  watched  such  cases 
must  have  observed  that  rotation  often  occurs  spontaneously  at  a  very 
advanced  period  of  labor,  long  after  the  head  has  been  pressed  down  for 
a  considerable  time  to  the  very  outlet  of  the  pelvis,  and  when  it  seems  to 
have  been  making  fruitless  endeavors  to  emerge ;  so  that  a  little  patience 
will  often  be  sufficient  to  overcome  the  difficulty. 

When  Necessary,  the  Forceps  may  be  Used. — In  the  event  of  assistance 
being  absolutely  required  there  is  no  reason  why  the  forceps  should  not 
be  used.  The  instrument  is  not  more  difficult  to  apply  than  under 
ordinary  circumstances,  nor,  as  a  rule,  is  much  more  traction  necessary. 
Dr.  Macdonald,  indeed,  in  the  paper  already  alluded  to,  maintains  that 
in  persistent  occipito-posterior  positions  there  is  almost  always  a  want  of 
proportion  between  the  head  and  the  pelvis,  and  that,  therefore,  the 
forceps  will  be  generally  required ;  and  he  prefers  them  to  any  artificial 
attempts  at  rectification.  Some  peculiarities  in  the  mode  of  delivery  are 
necessary  to  bear  in  mind.  In  most  works  it  is  taught  that  the  operator 
should  pay  special  attention  to  the  rotation  of  the  head,  and  should 
endeavor  to  impart  this  movement  by  turning  the  occiput  forward  during 
extraction.  Thus,  Tyler  Smith  says  :  "  In  delivery  with  the  forceps  in 
occipito-posterior  presentations  the  head  should  be  slowly  rotated  during 
the  process  of  extraction,  so  as  to  bring  the  vertex  toward  the  pubic 
arch,  and  thus  convert  them  into  occipito-anterior  presentations."  The 
danger  accompanying  any  forcible  attempt  at  artificial  rotation  will, 
however,  be  evident  on  slight  consideration.  It  is  true  that  in  many 
cases,  when  simple  traction  is  applied,  the  occiput  will  of  itself  rotate 
forward,  carrying  the  instrument  with  it.  But  that  is  a  very  different 
thing  from  forcibly  tAvisting  round  the  head  with  the  blades  of  the 
forceps,  without  any  assurance  that  the  body  of  the  child  will  follow  the 
movement.     It  is  impossible  to  conceive  that  such  violent  interference 

^  System  of  Obstetrics,  p.  308. 


DIFFICULT  OCCIPITO-POSTERIOR  POSITIONS.  321 

should  not  be  attended  with  serious  risk  of  injury  to  the  neck  of  the 
child.  If  rotation  do  not  occur,  the  fair  inference  is  that  the  head  is  so 
placed  as  to  render  delivery  with  the  face  to  the  pubes  the  best  termina- 
tion, and  no  endeavor  should  be  made  to  prevent  it.  This  rule  of 
leaving  the  rotation  entirely  to  nature,  and  using  traction  only,  has 
received  the  approval  of  Barnes  and  most  modern  authorities,  and  is 
the  one  which  recommends  itself  as  the  most  scientific  and  reasonable. 

Objection  to  Curved  Instruments  in  such  Cases. — There  are  cases  in 
which  the  pelvic  curve  of  the  forceps  is  of  doubtful  utility.  When 
applied  in  the  usual  way  the  convexity  of  the  blades  points  backward. 
If  rotation  accompany  extraction,  the  blades  necessarily  follow  the 
movement  of  the  head,  and  their  convex  edges  will  turn  forward.  It 
certainly  seems  probable  that  such  a  movement  would  subject  the 
maternal  soft  parts  to  considerable  risk.  I  have,  however,  more  than 
once  seen  such  rotation  of  the  instrument  happen  without  any  apparent 
bad  result ;  but  the  dangers  are  obvious.  Hence  it  would  be  a  wise  pre- 
caution either  to  use  a  pair  of  straight  forceps  for  this  particular  opera- 
tion, or  to  remove  the  blades  and  leave  the  case  to  be  terminated  by  the 
natural  powers  when  the  head  is  at  the  lower  strait  and  rotation  seems 
about  to  occur.  When  there  is  no  rotation,  more  than  usual  care  should 
be  taken  with  the  perineum,  which  is  necessarily  much  stretched  by  the 
rounded  occijDut.  Indeed,  the  risk  to  the  perineum  is  very  considerable, 
and  even  with  the  greatest  care  it  may  be  impossible  to  avoid  laceration. 

Bearing  these  precautions  in  mind,  delivery  with  the  forceps  in  occipito- 
posterior  positions  offers  no  special  difficulties  or  dangers. 

[  Version  by  the  Vertex. — In  order  to  adapt  this  section  to  American 
practice,  I  addressed  letters  of  inquiry  upon  the  management  of  occipito- 
posterior  positions  to  several  obstetrical  professors  and  teachers,  and  have 
prepared  these  instructions  in  accordance  with  their  views. 

1.  "In  primitive  oblique  occipito-posterior  positions  of  the  head 
nature  will  almost,  without  exception,  cause  spontaneous  rotation  of  the 
occiput  to  the  symphysis  pubis ;  but  to  favor  this  movement  the  bag  of 
waters  jhoulcl  be  preserved." 

2.  "Spontaneous  rotation,  as  a  rule,  does  not  begin  until  the  head 
meets  with  resistance  from  the  floor  of  the  pelvis  ;  hence  no  effort  to 
force  rotation  should  be  made  until  Nature  has  proved  herself  inadequate." 

3.  Where  rotation  forward  is  prevented,  it  is  probably  due  to  the 
position  of  the  occiput  having  been  originally  directly  backward,  and 
only  becoming  oblique  after  the  descent  of  the  head  into  the  pelvis,  the 
position  of  the  child's  body  preventing  the  anterior  movement  of  its 
occiput.  That  is,  the  sixth  position  of  Hodge  has  changed  into  a  fourth 
or  fifth,  but  will  not  without  assistance  become  a  first  or  second. 

4.  If,  then,  rotation  is  not  spontaneous  after  the  head  reaches  the 
floor  of  the  pelvis,  version  })y  the  vertex  will  not  take  place  except  it  be 
forced  by  the  vectis  or  forceps. 

One  professor  writes  :  "  I  have  thus  far  succeeded  so  well"  (i.  e.  by 
the  vectis  and  forceps)  "that  I  recall  but  one  instanc^e  in  which  the  head 
was  born  with  the  occiput  looking  to  the  sacrum."  Another  says  he 
a|)j)lif!s  th(!  forceps  and  lets  "the  progress  of  the  head  determine  the 
mode  by  which  it  shall  make  its  exit,  not  trying  to  turn  by  the  fi)r(;e])s." 
21 


322  LABOR. 

In  the  primitive  oecipito-sacral  position  changed  to  oblique,  or  in  the 
more  rare  unchanged  sixth  position  of  Hodge,  if  the  head  is  large  or  the 
pelvis  in  any  way  obstructed,  the  case  may  require  to  be  terminated  by 
craniotomy.  It  is  even  possible  to  rotate  the  occiput  from  the  sacrum 
to  the  pubes  and  save  the  child,  as  this  was  once  done  by  the  late  Dr. 
William  Harris  of  Philadelphia.  Of  course  the  body  must  have  partly 
rotated. 

Use  of  the  Hand  in  Oceipito-posterior  Positions. — The  introduction 
of  the  hand  for  the  purpose  of  effecting  version  by  the  vertex,  under  an 
anaesthetic,  was  strongly  advocated  by  the  late  Dr.  John  S.  Parry'  of 
Philadelphia,  who  certainly  used  his  own,  which  was  small  and  thin,  to 
very  great  advantage.  Several  very  small-handed  accoucheurs  in  this 
city  have  found  their  hands  of  very  great  value  in  some  cases  of 
obstetrics  ;  and  it  is  said  that  a  celebrated  Neapolitan  obstetrician  owes 
his  great  popularity  to  the  advantage  thus  derived.  It  will  not  do  to 
advocate  a  general  use  of  the  hand  in  obstetric  practice,  as  few  have  such 
as  it  would  be  safe  to  use,  especially  in  primiparse.  I  have  known  a 
primipara  labor  for  hours  to  deliver  herself  of  a  foetus  in  an  occipito- 
posterior  position,  when  all  that  was  needed  was  the  assistance  of  a 
suitable  hand  during  three  labor-pains  to  bring  the  occiput  fairly  under 
the  arch  of  the  pubis. — Ed.] 


CHAPTER   VIII, 


PEESENTATIONS  OF  THE  SHOULDER,   AEM,  OR  TRUNK— COMPLEX 
PRESENTATIONS— PROLAPSE  OF  THE  FUNIS. 

In  the  presentations  already  considered  the  long  diameter  of  the  foetus 
corresponded  with  that  of  the  uterine  cavity,  and  in  all  of  them  the  birth 
of  the  child  by  the  maternal  efforts  was  the  general  and  normal  termina- 
tion of  labor.  We  have  now  to  discuss  those  important  cases  in  which 
the  long  diameter  of  the  foetus  and  uterus  do  not  correspond,  but  in 
which  the  long  foetal  diameter  lies  obliquely  across  the  uterine  cavity. 
In  the  large  majority  of  these  it  is  either  the  shoulder  or  some  part  of 
the  upper  "extremity  that  presents ;  for  it  is  an  admitted  fact  that, 
although  other  parts  of  the  body,  such  as  the  back  or  abdomen,  may,  in 
exceptional  cases,  lie  over  the  os  at  an  early  period  of  labor,  yet  as  labor 
progresses  such  presentations  are  almost  always  converted  into  those  of 
the  upper  extremity. 

For  all  practical  purposes,  we  may  confine  ourselves  to  a  considera- 
tion of  shoulder  presentations,  the  further  subdivision  of  these  into  elbov^ 
or  hand  presentations  being  no  more  necessary  than  the  division  of  pel- 
vis presentations  into  breech,  knee,  and  footling  cases,  since  the  mechan- 
ism and  management  are  identical  whatever  part  of  the  upper  extremity 
presents. 

[^  Am.  Jonrn.  Ob.'^teiriot,  May,  1875,] 


PEESENTATIONS  OF  SHOULDER,   ETC. 


323 


Delivery  by  the  Natural  Powers  is  Quite  Exceptional. — There  is  this 
great  distinction  between  the  presentations  we  are  now  considering  and 
those  ah-eadj  treated  of :  that,  on  account  of  the  relations  of  the  foetus 
to  the  pelvis,  delivery  by  the  natural  powers  is  impossible,  except  under 
special  and  very  unusual  circumstances  that  can  never  be  relied  upon. 
Intervention  on  the  part  of  the  accoucheur  is  therefore  absolutely  essen- 
tial, and  the  safety  of  both  the  mother  and  child  depends  upon  the  early 
detection  of  the  abnormal  position  of  the  foetus ;  for  the  necessary  treat- 
ment, which  is  comparatively  easy  and  safe  before  labor  has  been  long 
in  progress,  becomes  most  difficult  and  hazardous  if  there  have  been 
much  delay. 

Position  of  the  Foetus. — Presentations  of  the  upper  extremity  or  trunk 
are  often  spoken  of  as  "  trcmsmrse ^presentations  "  or  "  cross-births  ; " 
but  both  of  these  terms  are  misleading,  as  they  imply  that  the  foetus  is 
placed  transversely  in  the  uterine  cavity  or  that  it  lies  directly  across  the 
pelvic  brim.  As  a  matter  of  fact,  this  is  never  the  case,  for  the  child 
lies  obliquely  in  the  uterus — not  indeed  in  its  long  axis,  but  in  one  inter- 
mediate between  its  long  and  transverse  diameters. 

Divided  into  Dor  so-anterior  and  Dorso-posterior  Positions. — Two 
great  divisions  of  shoulder  presentations  are  recognized :   the  one   in 

Fig.  116. 


Dorsoanterior  Presentation  of  the  Arm. 


which  the  back  of  the  child  looks  to  the  abdomen  of  the  mother  (Fig. 
110),  and  the  otlier  in  which  the  back  of  the  child  is  turned  toward  the 
spine  of  the  motlier  (Fig.  117).  Each  of  these  is  subdivided  into  two 
subsidiary  chisses,  a(!(rording  as  the  head  of  the  child  is  placed  in  the 
right  or  left  iliac  ft)ssa.  Thus,  in  dorso-antcrior  positions,  if  the  head 
lie  in  the  left  iliac  fossa,  the  right  shoulder  of  the  child  presents;  if  in 
the  riglit  iliac  fossa,  the  left.  So  in  dorso-posterior  positi(ms,  if  the  head 
lie  in  tli(;  ksft  ilia(!  fossa,  the  left  shoulder  j^rescnts  ;  if  in  the  right,  the 
ri^^ht.  Of  th(!  two  class<!S,  tlu;  dorso-aiiterior  positions  are  more  com- 
mon,  in  i\\('.  pi'oj)orti()n,  it  is  said,  of  two  to  one. 


324 


LABOR. 


Causes. — The  causes  of  shoulder  presentation  are  not  well  known. 
Amongst  those  most  commonly  mentioned  are  prematurity  of  the  foetus 
and  excess  of  liquor  amnii ;  either  of  these,  by  increasing  the  mobility 
of  the  foetus  in  utero,  would  probably  have  considerable  influence.  The 
fact  that  it  occurs  much  more  frequently  amongst  premature  births  has 


Fig.  117. 


Dorso-posterior  Presentation  of  the  Arm. 

W^-W    long  been  recognized.    Undue  obliquity  of  the  uterus  has  probably  some 

;,<-    ,,,  influence,  since  the  early  pains  might  cause  the  presenting  part  to  hitch 

against  the  pelvic  brim  and  the  shoulder  to  descend.    An  unusually  low 

attachment  of  the  placenta  to  the  inferior  segment  of  the  uterine  cavity 

>r  ^cOi,  has  beeilnentioned  as  a  predisposing  cause.  In  consequence  of  this  the 
head  does  not  lie  so  readily  in  the  lower  uterine  segment,  and  is  apt  to 
slip  up  into  one  of  the  iliac  fossae.  This  is  supposed  to  explain  the  fre- 
quency of  arm  presentation  in  cases  of  partial  or  complete  placenta 
prsevia.  Danyau  and  Wigand  believe  that  shoulder  presentations  are 
favored  by  irregularity  in  the  shape  of  the  uterine  cavity,  especially  a 
relative  increase  in  its  transverse  diameter.  This  theory  has  been  gen- 
erally discredited  by  writers,  and  it  is  certainly  not  susceptible  of  proof ; 
but  it  seems  far  from  unlikely  that  some  peculiarity  of  shape  may  exist, 
not  capable  of  recognition,  but  sufficient  to  influence  the  position  of  the 
foetus.  How  otherwise  are  we  to  exjilain  those  remarkable  cases,  many 
of  which  are  recorded,  in  which  similar  malpositions  occurred  in  many 
successive  labors  ?  Thus,  Joulin  refers  to  a  patient  who  had  an  arm 
presentation  in  three  successive  pregnancies,  and  to  another  who  had 
shoulder  presentation  in  three  out  of  four  labors.  Certainly,  such  con- 
stant recurrences  of  the  same  abnormality  could  only  be  explained  on 
the  hypothesis  of  some  very  persistent  cause,  such  as  that  referred  to. 
Pinard^  states  that  shoulder  presentations  are  seven  times  more  common 
'  Annal.  d'Hyg.  Pub.  et  de  Med.,  Jan.,  1^79. 


PRESENTATIONS  OF  SHOULDER,  ETC.  325 

in  multiparse  than  in  primiparse,  in  consequence,  as  he  believes,  of  the 
laxity  of  the  abdominal  walls  in  the  former,  which  allows  the  uterus  to 
fall  forward,  and  thus  prevents  the  head  entering  the  pelvic  brim  in  the 
latter  weeks  of  pregnancy.  It  is  probable  that  merely  accidental  causes  TT  -  +*• 
have  most  influence  in  the  production  of  shoulder  presentation,  such  as  ~'^  >-  ►■  ^ 
falls  or  undue  pressure  exerted  on  the  abdomen  by  badly-fitting  or  tight 
stays.  Partially  transverse  positions  during  pregnancy  are  certainly 
much  more  common  than  is  generally  believed,  and  may  often  be 
detected  by  abdominal  palpation.  The  tendency  is  for  such  malposi- 
tions to  be  righted  either  before  labor  sets  in  or  in  the  early  period  of 
labor ;  but  it  is  quite  easy  to  understand  how  any  persistent  pressure, 
applied  in  the  manner  indicated,  may  perpetuate  a  position  which  other- 
wise would  have  been  only  temporary. 

Puggjiosis    and    Frequency.  —  According    to    Churchill's    statistics, 
shoulder  presentations  occur  about  once  in   260  cases ;    that  is,   only    1  u^  "3- 
slightly  less  frequently  than  those  of  the  face.     The  prognosis  to  both  I 
the  mother  and  chijxl^s^muchmore  unfavorable  ;  for  he  estimates  that,  ' 
out  of  235  cases,  1  in  9  of  the  mothers  andlialf  the  children  were  lost.-- 
The  prognosis  in  each  individual  case  will,  of  course,  vary  much  with 
the    period  of  delivery  at  which  the  malposition  is    recognized.     If 
detected  early,  interference  is  easy  and  the  prognosis  ought  to  be  good ; 
whereas  there  are  few  obstetric  difficulties  more  trying  than  a  case  of 
shoulder  presentation  in  which  the  necessary  treatment  has  been  delayed 
until  the  presenting  part  has  been  tightly  jammed  into  the  cavity  of  the 
pelvis. 

Diagnosis. — Bearing  this  fact  in  mind,  the  paramount  necessity  of  an 
accurate  diagnosis  will  be  apparent ;  and  it  is  specially  important  that 
we  should  be  able  not  only  to  detect  that  a  shoulder  or  arm  is  present- 
ing, but  that  we  should,  if  possible,  determine  which  it  is,  and  how  the 
body  and  head  of  the  child  are  placed.  The  existence  of  a  shoulder 
presentation  is  not  generally  suspected  until  the  first  vaginal  examination 
is  made  during  labor.  The  practitioner  will  then  be  struck  with  the 
absence  of  the  rounded  mass  of  the  foetal  head,  and,  if  the  os  be  open 
and  the  membranes  protruding,  by  their  elongated  form,  which  is  com- 
mon to  this  and  to  other  malpresentations.  If  the  presenting  part  be 
too  high  to  reach,  as  is  often  the  case  at  an  early  period  of  labor,  an 
endeavor  should  at  once  be  made  to  ascertain  the  foetal  position  by 
abdominal  examination.  This  is  the  more  important  as  it  is  much  more  fiJyei<  Cr 
easy  to  recognize  presentations  of  the  shoulder  in  this  way  than  those  — "" 
of  tlie  breech  or  foot ;  and  at  so  early  a  period  it  is  often  not  only  possi- 
])le,  but  comparatively  easy,  to  alter  the  position  of  the  foetus  by  abdom- 
inal manipulation  alone,  and  thus  avoid  the  necessity  of  the  more  serious 
form  of  version.  The  method  of  detecting  a  shoidder  presentation  by 
examination  of  the  abdomen  has  already  been  described  (p.  124),  and 
need  not  be  repeated.  The  ehicf _.pointsJo  look  for  arc  the  altered  shape 
of  the  uterus  and  two  solid  masses,  the  head  and  the  breech,  one  in  either 
W\w.  fossil.  Tli(!  facility  with  which  these  parts  may  Ik;  nKiognlzcd  varies  ' 
ninch  in  difl'crcnt  pati(;nts.  In  thin  women  with  lax  abdominal  |)ai"ietes 
llicy  can  be  easily  fi'lt,  while  in  very  stout  women  it  may  be  ini|)()ssil)le. 
Failing  this  method,  we  nuist  rely  on  vaginal  examinations,  although 


326  LABOR. 

before  the  membranes  are  ruptured,  and  when  the  presenting  part  is  high 
in  the  pelvis,  it  is  not  always  easy  to  gain  accurate  information  in  this 
way.  The  difficulty  is  increased  by  the  paramount  importance  of  retain- 
ing the  membranes  intact  as  long  as  possible.  It  should  be  remembered, 
therefore,  that  when  a  presentation  of  the  superior  extremity  is  suspected, 
the  necessary  examinations  should  only  be  made  in  the  intervals  between 
the  pains,  when  the  membranes  are  lax,  and  never  when  they  are  ren- 
dered tense  by  the  uterine  contractions. 

As  either  the  shoulder,  the  elbow,  or  the  hand  may  present,  it  will  be 
best  to  describe  the  peculiarities  of  each  separately,  and  the  means  of 
distinguishing  to  which  side  of  the  body  the  presenting  part  belongs. 

1.  Fecidim-ities  of  the  Shoulder. — The  shoulder  is  recognized  as  a 
round,  smooth  prominence,  at  one  point  of  which  may  often  be  felt  the 
sharp  edge  of  the  acromion.  If  the  finger  can  be  passed  sufficiently 
high,  it  may  be  possible  to  feel  the  clavicle  and  the  spine  of  the  scapula. 
A  still  more  complete  examination  may  enable  us  to  detect  the  ribs  and 
the  intercostal  spaces,  which  would  be  quite  conclusive  as  to  the  nature 
of  the  presentation,  since  there  is  nothing  resembling  them  in  any  other 
part  of  the  body.  At  the  side  of  the  shoulder  the  hollow  of  the  axilla 
may  generally  be  made  out.     * 

Mode  of  Diagnosing  the  Position  of  the  Child. — In  order  to  ascertain 
the  position  of  the  child  we  have  to  find  out  in  ^vhich  iliac  fossa  the  head 
lies.  This  may  be  done  in  two  ways  :  1st,  the  head  may  be  felt  through 
the  abdominal  parietes  by  palpation ;  and  2d,  since  the  axilla  always 
points  tqward  the  feet,  if  it  point  to  the  left  side  the  head  must  lie  in  the 
right  iliac  fossa ;  if  to  the  right,  the  head  must  be  placed  in  the  left  iliac 
fossa.  Again,  the  spine  of  the  scapula  must  correspond  to  the  back  of 
the  child,  the  claivicle  to  its  abdomen ;  and  by  feeling  one  or  other  we 
know  whether  we  have  to  do  with  a  dorso-anterior  or  dorso-posterior 
position.  If  we  cannot  satisfactorily  determine  the  position  by  these 
means,  it  is  quite  legitimate  practice  to  bring  down  the  arm  carefully, 
provided  the  membranes  are  ruptured,  so  as  to  examine  the  hand,  which 
will  be  easily  recognized  as  right  or  left.  This  expedient  will  decide 
the  point,  but  it  is  one  which  it  is  better  to  avoid  if  possible,  for  it  not 
only  slightly  increases  the  difficulty  of  turning,  although  perhaps  not 
very  materially,  but  the  arm  might  possibly  be  injured  in  the  endeavor 
to  bring  it  down. 

Differenticd.  Diagnosis  of  the  Shoulder. — The  only  part  of  the  body 
likely  to  be  taken  for  the  shoulder  is  the  breech ;  but  in  that  its  larger 
size,  the  groove  in  Avhich  the  genital  organs  lie,  the  second  prominence 
formed  by  the  other  buttock,  and  the  sacral  sjjinous  processes  are  suffi- 
cient to  prevent  a  mistake. 

2.  The  Elbow. — The  elbow  is  rarely  felt  at  the  os,  and  may  be  readily 
recognized  by  the  sharp  prominence  of  the  olecranon,  situated  between 
two  lesser  prominences,  the  condyles.  As  the  elbow  always  points 
toward  the  feet,  the  position  of  the  foetus  can  be  easily  ascertained. 

3.  The  Hand. — The  hand  is  easy  to  recognize,  and  can  only  be  con- 
founded with  the  foot.  It  can  be  distinguished  by  its  borders  being  of 
the  same  thickness,  by  the  fingers  being  wider  apart  and  more  readily 
separated  from  each  other  than  the  toes,  and  above  all  by  the  mobility 


PRESENTATIONS  OF  SHOULDER,   ETC.  327 

of  the  thumb,  which  can  be  carried  across  the  pahn  and  placed  in  appo- 
sition with  each  of  the  fingers. 

Mode  of  I)etectm(ijichich  Hand  is  Presenting. — It  is  not  difficult  to 
tell  which  hand  is  presenting.     If  the  hand  be  in  the  vagina  or  beyond  ' 
the  vulva,  and  within  easy  reach,  we  recognize  which  it  is  by  laying  hold 
of  it  as  if  we  were  about  to  shake  hands.     If  the  palm  lie  in  the  palm 
of  the  practitioner's  hand  with  the  two  thumbs  in  apposition,  it  is  the 
right  hand ;  if  the  back  of  the  hand,  it  is  the  left.    Another  simple  way    i 
is  for  the  practitioner  to  imagine  his  own  hand  placed  in  precisely  the    i 
same  position  as  that  of  the  foetus,  and  this  will  readily  enable  him  to    | 
verify  the  previous  diagnosis.     A  simple  rule  tells  us  how  the  body  of 
the  child  is  placed,  for,  provided  we  are  sure  the  hand  is  in  a  state  of 
supination,  the  back  of  the  hand  points  to  the  back  of  the  child,  the 
palm  to  its  abdomen,  the  thumb  to  the  head,  and  the  little  finger  to 
the  feet. 

llechanism. — It  is  perhaps  hardly  proper  to  talk  of  a  mechanism  of 
shoulder  presentations,  since  if  left  unassisted  they  almost  invariably 
lead  to  the  gravest  consequences.  Still,  Nature  is  not  entirely  at  fault 
even  here,  and  it  is  well  to  study  the  means  she  adopts  to  terminate 
these  malpositions. 

Terminations. — There  are  two  possible  terminations  of  shoulder  pres-  ^ 
entation.  In  one,  known  as  "  sj)ontaneous  version,"  some  other  part  of  - 
the  foetus  is  substituted  for  that  originally  presenting ;  in  the  other, 
^'  spontaneous  evolution,"  the  foetus  is  expelled  by  being  squeezed  through  . 
the  pelvis,  without  the  originally  presenting  part  being  withdrawn.  It  ,- 
cannot  be  too  strongly  impressed  on  the  mind  that  neither  of  these  can 
be  relied  on  in  practice. 

Spontaneous  version  may  occasionally  occur  before  or  immediately  "T 
after  the  rupture  of  the  membranes,  when  the  foetus  is  still  readily 
movable  within  the  cavity  of  the  uterus.  A  few  authenticated  cases  are 
recorded  in  which  the  same  fortunate  issue  took  place  after  the  shoulder 
had  been  engaged  in  the  pelvic  brim  for  a  considerable  time,  or  even 
after  prolapse  of  the  arm  ;  but  its  probability  is  necessarily  much  less- 
ened under  such  circumstances.  Either  the  head  or  the  breech  may  be 
brought  down  to  the  os  in  place  of  the  original  presentation. 
.  The  precise  mechanism  of  spontaneous  version,  or  the  favoring  cir- 
cumstances, are  not  sufficiently  understood  to  justify  any  positive  state- 
ment with  regard  to  it.  C^-.^'^-A. 

Cazeaux  believed  that  it  is  produced  by  partial  or  irregular  contrac- 
tion of  the  uterus,  one  side  contracting  energetically,  while  the  other  ^, 
remains  inert  or  only  contracts  to  a  slight  degree.     To  illustrate  how  v 
this  may  effect  spontaneous  version,  let  us  su])pose  that  the  child  is  lying  Sw^^-^^^-a 
with  the  head  in  the  left  iliac  fossa.     Then,  if  the  left  side  of  the  uterus   *"^  ^^'^"■'^^ 
should  contract  more  forcibly  than  tlic  right,  it  would  clearly  tend  to 
pusli  the  head  and  shoiddcr  to  the  right  side  until  the  head  came  to  pre- 
sent instead  of  the  shoulder.     A  very  interesting  case  is  related  by 
GeneuiP  in  which  he  was  present  during  spontaneous  version,  in  the 
course  of  which  the  breech  was  substituted  for  the  left  shoulder  more 
tiiaii  foiii-  hours  after  the  rupture  of  the  membranes.      In  this  case  the 

'  Ann.  de  Oynecolngic,  vol.  v.,  1S76. 


328  LABOR. 

viterus  was  so  tightly  contracted  that  version  was  impossible.     He  ob- 
served the  side  of  the  uterus  oj^posite  the  head  contracting;  energetically, 
,  the  other  remaining  flaccid,  and  eventually  the  case  ended  without  assist- 
ance, the  breech  presenting.    The  natural  moulding  action  of  the  uterus, 
and  the  greater  tendency  of  the  long  axis  of  the  child  to  lie  in  that  of 
i  "':'■"'  '"  the  uterus,  no  doubt  assist  the  transformation ;  and  much  must  depend 
"'""' "     on  the  mobility  of  the  foetus  in  any  individual  case. 

That  such  changes  often  take  place  in  the  latter  weeks  of  pregnancy, 
and  before  labor  has  actually  commenced,  is  quite  certain,  and  they  are 
probably  much  more  frequent  than  is  generally  supposed.  When  spon- 
taneous version  does  occur,  it  is  of  course  a  more  favorable  event ;  and 
the  termination  and  prognosis  of  the  labor  are  then  the  same  as  if  the 
head  or  breech  had  originally  presented. 

Sjjontaneous  Evolution. — The  mechanism  of  spontaneous  evolution, 

since  it  was  first  clearly  worked  out  by  Douglas,  has  been  so  often  and 

carefully  described  that  we  know  precisely  how  it  occurs.     Although 

every  now  and  then  a  case  is  recorded  in  which  a  living  child  has  Ijeen 

born  by  this  means,  such  an  event  is  of  extreme  rarity ;  and  there  is  no 

doubt  of  the  accuracy  of  the  general  opinion,  that  spontaneous  evolution. 

„A*4|iUvv.  ^^  oJ^ly  happen  when  the  pelvis  is  unusually  roomy  and  the  child 

uLvtc^  small,  and  that  it  almost  necessarily  involves  the  death  of  the  foetus, 

^Ji .         on  account  of  the  immense  pressure  to  which  it  is  subjected. 

Two  varieties  are  described,  in  one  of  which  the  head  is  first  born,  in 
the  other  the  breech ;  in  both  the  originally  jjresenting  arm  remained 
prolapsed.  The  former  is  of  extreme  rarity,  and  is  believed  only  to 
have  happened  with  very  premature  children,  whose  bodies  were  small 
and  flexible,  and  when  traction  had  been  made  on  the  presenting  arm. 
Under  such  circumstances  it  can  hardly  be  called  a  natural  process,  and 
we  may  confine  our  attention  to  the  latter  and  more  common  variety. 

What  takes  place  is  as  follows :  The  presenting  arm  and  shoulder  are 
tightly  jammed  down,  as  far  as  is  possible,  by  the  uterine  contractions, 
and  the  head  becomes  strongly  flexed  on  the  shoulder.  As  much  of  the 
body  of  the  foetus  as  the  pelvis  will  contain  becomes  engaged,  and  then 
a  movement  of  rotation  occurs  which  brings  the  body  of  the  child  nearly 
into  the  antero-posterior  diameter  of  the  pelvis  (Fig.  118).  The  shoul- 
der projects  under  the  arch  of  the  pubes,  the  head  lying  above  the  sym- 
physis and  the  breech  near  the  sacro-iliac  synchondrosis.  It  is  essential 
that  the  head  should  lie  forward  above  the  pubes,  so  that  the  length  of 
the  neck  may  permit  the  shoulder  to  project  under  the  pubic  arch,  with- 
out any  part  of  the  head  entering  the  pelvic  cavity.  The  shoulder  and 
neck  of  the  child  now  become  fixed  points  round  which  the  body  of  the 
child  rotates,  and  the  whole  force  of  the  uterine  contractions  is  expended 
on  the  breech.  The  latter,  M'itli  the  body,  therefore  becomes  more  and 
more  depressed,  until  at  last  the  side  of  the  thorax  reaches  the  vulva, 
and,  followed  by  the  breech  and  inferior  extremities,  is  slowly  pushed 
out.     As  soon  as  the  limbs  are  born  the  head  is  easily  expelled. 

The  enormous  pressure  to  which  the  body  is  subjected  in  this  process 
can  readily  be  understood.  As  regards  the  practical  bearings  of  this 
termination  of  shoulder  presentations,  all  that  need  be  said  is,  that  if 
we  should  happen  to  meet  Avith  a  case  in  which  the  shoulder  and  thorax 


PRESENTATIONS  OF  SHOULDER,   ETC. 


329 


were  so  strongly  depressed  that  turning  was  impossible,  and  in  which  it 
seemed  that  nature  was  endeavoring  to  effect  evolution,  we  should  be 
justified  in  aiding  the  descent  of  the  breech  by  traction  on  the  gi'oin 
before  resorting  to  the  difficult  and  hazardous  operation  of  embryotomy 
or  decapitation. 

Treatment. — It  is  unnecessary  to  describe  specially  the  treatment  of 
shoulder  presentation,  since  it  consists  essentially  in  performing  the 
operation  of  turning,  which  is  fully  described  elsewhere.     It  is  only 

Fig.  118. 


Spontaneous  Evolution.    (After  Chiara  of  Milan.) 
This  drawing  was  made  from  a  patieut  who  died  undelivered,  the  body  being  frozen  and  bisected. 

needful  here  to  insist  on  the  advisability  of  performing  the  operation 
in  the  way  which  involves  the  least  interference  with  the  uterus.  Hence 
if  the  nature  of  the  case  be  detected  before  the  raeml^ranes  are  ruptured, 
an  endeavor  should  be  made — and  ouglit  generally  to  succeed — to  turn 
by  external  mani]:)iilation  only.  If  we  can  succeed  in  bringing  the 
brcfifh  or  head  over  tlie  os  in  this  'vvay,  the  case  will  be  little  juore 
troublesome  than  an  ordinary  presentation  of  these  parts.  Failing  in 
this,  turning  by  combined  external  and  internal  manipulation  should  be 
attf-mpted,  and  the  introdu(;tion  of  the  entire  hand  sliould  be  reserved 
for  tlios(!  inor(!  tronblcsonie  cases  in  whi(;li  the;  waU^rs  luive  long  drained 
away  and  in  which  hotli  \\iv.^v.  methods  arc  inap[)licablc. 


330  LABOR. 

Should  all  these  means  fail,  we  must  resort  to  the  mutilation  of  the 
child  by  embryulcia  or  decapitation,  probably  the  most  difficult  and 
dangerous  of  all  obstetric  operations.  ['] 

Coriijjlex  PrcHentdtion^. — There  are  various  so-called  complex  prcxeidd- 
tions  in  which  more  than  one  part  of  the  foetal  Ijody  presents.  Thus  we 
may  have  a  hand  or  a  foot  presenting  M'ith  the  head,  or  a  foot  and  hand 
presenting  simultaneously.  The  former  does  not  necessarily  give  rise  to 
any  serious  difficulty,  for  there  is  generally  sufficient  room  for  the  head 
to  pass.  Indeed,  it  is  unlikely  that  either  the  hand  or  foot  should  enter 
the  pelvic  brim  with  the  head  unless  the  head  was  unusually  small  or 
the  pelvis  more  than  ordinarily  capacious.  As  regards  treatment,  it  is 
no  doubt  advisable  to  make  an  attempt  to  replace  the  hand  or  foot  by 
pushing  it  gently  above  the  head  in  the  intervals  between  the  pains, 
and  maintaining  it  there  until  the  head  be  fully  engaged  in  the  pelvic 
cavity.  The  engagement  of  the  head  can  be  hastened  by  abdominal 
pressure,  which  will  prove  of  great  value.  Failing  this,  all  we  can  do 
is  to  place  the  presenting  member  at  the  part  of  the  pelvis  where  it 
will  least  impede  the  labor  and  be  the  least  subjected  to  pressure  ;  and 
that  will  generally  be  opposite  the  temple  of  the  child.  As  it  must 
obstruct  the  passage  of  the  head  to  a  certain  extent,  the  application  of 
(the  forceps  may  be  necessary.  When  the  feet  and  hands  present  at  the 
jsame  time,  in  addition  to  the  confusing  nature  of  the  presentation  from 
I  so  many  parts  being  felt  together,  there  is  the  risk  of  the  hands  com- 
ling  down  and  converting  the  case  into  one  of  arm  presentation.  It 
■is  the  obvious  duty  of  the  accoucheur  to  prevent  this  by  ensuring  the 
descent  of  the  feet,  and  traction  should  be  made  on  them,  either  Avith 
the  fingers  or  with  a  lac,  until  their  descent  and  the  ascent  of  the  hands 
are  assured. 

Dorsal  Di&jilacement  of  the  Arm. — In  connection  Avith  this  subject 
may  be  mentioned  the  curious  dorsal  displacement  of  the  arm,  first 

\}  Accoucheurs  and  surgeons  have  thought  proper  to  perform  the  C»esarean  opera- 
tion m  the  United  States  in  11  cases  where  the  foetus  was  dead  and  impacted  in  tlie 
pelvis  in  a  transverse  position,  and  of  these  8  were  saved,  or  72/y  per  cent.  In  9  of 
the  cases  the  arm  protruded.  In  3  the  pelvis  was  small,  but  in  two  of  these,  small  chil- 
dren have  since  been  delivered  alive  naturally.  In  no  case  in  the  list  was  there  any 
evidence  of  pelvic  disease.  In  a  twelfth  case,  where  there  had  been  rickets  in  child- 
hood, and  in  which  the  arm  protruded,  there  was  likewise  a  saving  of  tlie  woman  ;  but 
this  one  is  excluded  from  the  record,  on  account  of  the  true  cause  of  dystocia  not 
having  been  the  position  of  the  ibetus.  Case  3  was  in  labor  96  hours,  3  days  of  this 
time  under  a  midwife,  and  died  of  exhaustion  in  17  hours.  Cass  7  was  also  in  tlie  care 
of  a  midwife,  and  died  of  exhaustion  in  12  hours,  having  been  much  prostrated  at  the 
time  of  the  operation.  Case  9  was  in  a  fair  way  to  recover  when  her  husband  canie 
home  intoxicated,  and  she  arose  from  her  bed  to  protect  her  mother  from  him.  This 
fright,  excitement,  and  exertion  caused  her  deatli  in  a  lew  hours  three  and  a  half  days 
after  the  operation. 

The  celebrated  case  of  Le  Bras  of  Mouilleron  in  1769,  in  which  the  uterus  was  for 
the  first  time  sutured,  was  one  of  arm  protrusion,  with  impaction,  after  three  days' 
labor  under  a  midwife:  this  patient  also  recovered.  Le  IJras  was  much  censured  for 
his  operation,  although  Dr.  Lyonnet  had  labored  a  long  time  to  deliver  per  vias  nata- 
rales  before  he  was  called  in/and  particularly  for  the  additional  risk  of  inserting  a 
movable  suture  in  the  uterus.  Certainly  the  results  of  these  American  operations  are 
encouraging  in  this  class  of  cases.  Case  11  was  operated  upon  in  June,  1880,  and  had 
two  silver-wire  uterine  sutures  inserted  :  she  was  well  in  a  month,  pregnant  in  two  and 
a  half  more,  and  bore  a  child  naturally  in  twelve  and  a  lialf  months  after  the  opera- 
tion.    Can  craniotomy  and  evisceration  show  anv  more  favorable  results? — Ed.] 


PRESENTATIONS  OF  SHOULDER,  ETC. 


331 


described  by  Sir  James  Simpson/  in  which  the  forearm  of  the  child 
becomes  thrown  across  and  behind  the  neck.  The  result  is  the  forma- 
tion of  a  ridge  or  bar,  which  prevents  the  descent  of  the  head  into  the 
pelvis  by  hitching  against  the  brim  (Fig.  119).  The  difficulty  of  diag- 
nosis is  very  great,  for  the  cause  of  obstruction  is  too  high  up  to  be  felt. 
But  if  we  meet  with  a  case  in  which  the  pelvis  is  roomy  and  the  pains 
strong,  and  yet  the  head  does  not  descend  after  an  adequate  time,  a  full 
explanation  of  the  cause  is  essential.  For  this  purpose  we  would  natu- 
rally put  the  patient  under  chloroform  and  pass  the  hand  sufficiently  high. 


Fig.  119. 


Dorsal  Displacement  of  the 
Arm. 


Dorsal  Displacement  of  the  Arm  in  Footling 
Presentations.    (After  Barnes.) 


We  might  then  feel  the  arm  in  its  abnormal  position.  That  was  what 
took  place  in  a  case  under  my  own  care,  in  Avhich  I  failed  to  get  the 
head  through  the  brim  with  the  forceps,  and  eventually  delivered  by 
turning.  The  same  course  was  adopted  by  my  friend  Mr.  Jardine 
Murray  in  a  similar  case.^  Simpson  advises  that  the  arm  should  be 
]>rouglit  down,  so  as  to  convert  the  case  into  an  ordinary  hand-and-head 
presentation.  This,  if  the  arm  be  above  the  brim,  must  always  be  diffi- 
ciih,  and  I  b(!]ieve  the  simpler  and  more  effec^tive  plan  is  podalic  version. 
A  similar  displacement  may  cause  some  difficulty  in  breech  presenta- 
tions and  after  turning  (Fig.  120).  Delay  here  is  easier  of  diagnosis, 
sincx3  the  obstacle  to  the  ex])ulsio)i  will  at  once  lead  to  careful  examina- 
tion. Wy  carrying  the  body  of  the  child  well  baxjkward,  so  as  to  enable 
'  ScM'cted  ObMet.  Works,  vol.  i.  ^  Med.  Times  and  Oaz.,  1861. 


332 


LABOR. 


the  finger  to  pass  behind  the  symphysis  pubis  and  over  the  shoulder,  it 
will  generally  be  easy  to  liberate  the  arm. 

Prolapse  of  the  Umbilical  Cord. — It  occasionally  happens  that  the 
umbilical  cord  falls  down  past  the  presenting  part  (Fig.  121),  and  is  apt 
to  be  pressed  between  it  and  the  walls  of  the  pelvis.  The  consequence 
is,  that  the  foetal  circulation  is  seriously  interfered  with,  and  the  death 

Fig.  121. 


Prolapse  of  the  Umbilical  Cord. 


of  the  child  from  asphyxia  is  a  common  result.  Hence  prolapse  of  the 
funis  is  a  very  serious  complication  of  labor  in  so  far  as  the  child  is 
concerned. 

Frequency. — Fortunately,  it  is  not  a  very  frequent  occurrence. 
Churchill  calculates  that  out  of  over  105,000  deliveries  it  was  met  with 
once  in  240  cases,  and  Scanzoni  once  in  254.  Its  frequency  varies  much 
under  different  circumstances  and  in  different  places.  We  find  from 
Churchill's  figures  a  remarkable  difference  in  the  proportional  number 
of  cases  observed  in  France,  England,  and  Germany — viz.  1  in  446-|-, 
1  in  207-^,  and  1  in  156,  respectively.  Great  as  is  the  proportion 
referred  to  Germany  in  these  figures,  it  has  been  found  to  be  exceeded  in 
special  districts.  Thus,  Engclmann  records  1  case  out  of  94  labors  in 
the  Lying-in  Hospital  at  Berlin,  and  Michaelis  1  in  90  in  that  of  Kiel. 
These  remarkable  differences  are  at  first  sight  not  easy  to  accoinit  for. 
Dr.  Simpson  suggests,  with  considerable  show  of  probability,  that  the 
difference  in  frequency  in  England,  France,  and  Germany  may  depend 
on  the  varying  positions  in  ^vhich  lying-in  ^^omen  are  placed  during 
labor  in  each  country.  In  France,  where,  although  the  patient  is  laid 
on  her  back,  the  j^elvis  is  kept  elevated,  the  complication  occurs  least  fre- 
quently ;  in  England,  Avhere  she  lies  on  her  side,  more  often  ;  and  in 
Germany,  where  she  is  placed  on  her  back  with  her  shoulders  raised. 


PRESENTATIONS  OF  SHOULDER,   ETC.  333 

most  often.  The  special  frequency  of  prolapsed  funis  in  certain  districts,! 
as  in  Kiel,  is  supposed  by  Engelmann'  to  depend  on  the  prevalence  of  i 
rickets,_and  consequently  of  deformed  pelvis,  which  we  shall  presently  i 
see  is  probably  one  of  the  most  frequent  and  important  causes  of  the 
accident. 

Progjwsis. — With  regard  to  the  danger  attending  prolapsed  funis,  as 
far  as  the  mother  is  concerned  it  may  be  said  to  be  altogether  unimport- 
ant ;  but  the  universal  experience  of  obstetricians  points  to  the  great  risk 
to  which  the  child  is  subjected.  Scanzoni  calculates  that  45  per  cent, 
only  of  the  children  were  saved ;  Churchill  estimated  the  number  at  47 
per  cent. ;  thus,  under  the  most  favorable  circumstances,  this  complica- 
tion leads  to  the  death  of  more  than  half  the  children.  Ena;elmann 
found  that  out  of  202  vertex  presentations  only  36  per  cent,  of  the  chil- 
dren survived.  The  mortality  was  not  nearly  so  great  in  other  pres- 
entations; 68  per  cent,  of  the  cases  in  which  the  child  presented  with 
the  feet  were  saved,  and  50  per  cent,  in  original  shoulder  presentations. 
The  reason  of  this  remarkable  difference  is,  doubtless,  that  in  vertex 
presentations  the  head  fits  the  pelvis  much  more  completely  and  subjects 
the  chord  to  much  greater  pressure,  while  in  other  presentations  the  pel- 
vis is  less  completely  filled  and  the  interference  with  the  circulation  in 
the  cord  is  not  so  great.  Besides,  in  the  latter  case  the  complication  is 
detected  early  and  the  necessary  treatment  sooner  adopted. 

The  foetal  mortality  is  considerably  greater  in  first  labors — a  result  to 
be  expected  on  account  of  the  greater  resistance  of  the  sofib  parts  and 
the  consequent  prolongation  of  the  labor. 

Causes. — The  causes  of  prolapse  of  the  funis  are  any  circumstances  1 
which  prevent  the  presenting  part  accurately  fitting  the  pelvic  brim. ' 
Hence  it  is  much  more  frequent  in  face,  breech,  or  shoulder  than  in  ver- 
tex presentations,  and  is  relatively  more  common  in  footling  and  shoul- 
der presentations  than  in  any  other.  Amongst  occasional  accidental 
predisposing  causes  may  be  mentioned  early  rupture  of  the  membranes, 
especially  if  the  amount  of  liquor  amnii  be  excessive,  as  the  sudden 
escape  of  the  fluid  washes  down  the  cord ;  undue  length  of  the  cord 
itself;  or  an  unusually  low  placental  attachment.  Engelmann  attaches 
great  importance  to  slight  contraction  of  the  pelvis,  and  states  that  in 
the  Berlin  Lying-in  Hospital,  where  accurate  measurements  of  the  pel- 
vis were  taken  in  all  cases,  it  was  almost  invariably  found  to  exist.  The 
explanation  is  evident,  since  one  of  the  first  results  of  pelvic  contraction 
is  to  prevent  the  ready  engagement  of  the  presenting  part  in  the  pelvic 
brim. 

Diagnosis. — The  diagnosis  of  cord  presentation  is  generally  devoid 
of  difficulty,  but  if  the  membranes  are  still  unruptured  it  may  not  always 
ha  quite  easy  to  determine  the  precise  nature  of  tlie  soft  structures  felt 
through  them,  as  they  recede  from  the  touch.  If  the  pulsations  of  the 
cord  can  be  felt  thnnigh  tlie  membrancH,  all  difficulty  is  removed.  After 
the  membranes  are  ruj^tured  there  is  nothing  that  it  can  well  be  mis- 
taken for. 

Importance  of  Determining  the  Pulsations  of  the  Cord. — The  inqxirtant 
point  to  determine  in   such  a  case  is  whetlier  the  cord  be  pulsating  or 

^  Amer,  Journ.  of  Ohat.,  vol.  vi. 


334 


LABOR. 


not ;  for  if  pulsations  have  entirely  ceased  the  inference  is  that  the  child 
is  dead,  and  the  case  may  then  be  left  to  nature  without  further  interfe- 
rence. It  is  of  importance,  however,  to  be  careful,  for  if  the  examina- 
tion be  made  during  a  pain  the  circulation  might  be  only  temporarily 
arrested.  The  examination,  therefore,  should  be  made  during  an  inter- 
val, and  a  loop  of  the  cord  pulled  down,  if  necessary,  to  make  ourselves 
absolutely  certain  on  this  point. 

Amount  of  Cord  Prolapsed. — The  amount  of  the  prolapse  varies  much. 
Sometimes  only  a  knuckle  of  the  cord,  so  small  as  to  escape  observation, 
is  engaged  between  the  pelvis  and  presenting  part.  Under  such  circum- 
stances the  child  may  be  sacrificed  without  any  suspicion  of  danger  having 
arisen.  More  often  the  amount  prolapsed  is  considerable — sometimes  so 
as  to  lie  in  the  vagina  in  a  long  loop,  or  even  to  protrude  altogether 
beyond  the  vulva. 

Treatment. — In  the  treatment  the  great  indication  is  to  prevent  the 
cord  from  being  unduly  pressed  on,  and  all  our  endeavors  must  have 
this  object  in  view.  If  the  presentation  be  detected  before  the  full  dila- 
tation of  the  cervix  and  when  the  membranes  are  unruptured,  we  must 
try  to  keep  the  cord  out  of  the  way ;  to  preserve  the  membranes  intact 
as  long  as  possible,  since  the  cord  is  tolerably  protected  as  long  as  it  is 
surrounded  by  the  liquor  amnii ;  and  to  secure  the  complete  dilatation 
of  the  OS,  so  that  the  presenting  part  may  engage  rapidly  and  completely. 

Postural  Trecdment. — Much  may  be  done  at  this  time  by  the  postural 
treatment,  which  we  chiefly  owe  to  the  ingenuity  of  Dr.  T.  Gaillard 
Thomas  of  New  York,  whose  writings  familiarized  the  profession  with 
it,  although  it  appears  that  a  somewhat  similar  plan  had  been  occasion- 
ally adopted  previously.  Dr.  Thomas's  method  is  based  on  the  principle 
of  causing  the  cord  to  slip  back  into  the  uterine  cavity  by  its  own  weight. 

Fig.  122. 


Postural  Treatment  of  Prolapse  of  the  Cord. 

For  this  purpose  the  patient  is  placed  on  her  hands  and  knees,  witii  the 
hips  elevated  and  the  shoulders  resting  on  a  lower  level  (Fig.  122).  The 
cervix  is  then  no  longer  the  most  dependent  portion  of  the  uterus,  and 
the  anterior  wall  of  the  uterus  forms  an  inclined  plane  down  which  the 


PRESENTATIONS   OF  SHOULDER,   ETC.  335 

cord  slips.  The  success  of  this  manoeuvre  is  sometimes  very  great,  but 
by  no  means  always  so.  It  is  most  likely  to  succeed  when  the  mem- 
branes are  unruptured.  If",  when  adopted,  the  cord  slip  away  and  the 
OS  be  sufficiently  dilated,  the  membranes  may  be  ruptured,  and  engage- 
ment of  the  head  produced  by  properly-applied  uterine  pressure.  Some- 
times the  position  is  so  irksome  that  it  is  impossible  to  resort  to  it. 
Postural  treatment  is  not  even  then  altogether  impossible,  for  by  placing 
the  patient  on  the  side  opposite  to  that  of  the  prolapse,  so  as  to  relieve 
the  cord  as  much  as  possible  from  pressure,  and  at  the  same  time  elevat- 
ing the  hips  bv  a  pillow,  it  may  slip  back.  Even  after  the  membranes 
are  ruptured  postural  treatment  in  one  form  or  another  may  succeed ; 
and,  as  it  is  simple  and  harmless,  it  should  certainly  be  always  tried. 
Attempts  at  reposition  by  one  or  other  of  the  methods  described  below 
may  also  occasionally  be  facilitated  by  trying  them  when  the  patient  is 
placed  in  the  knee-shoulder  position. 

Artificial  Reposition. — Failing  by  postural  treatment,  or  in  combina- 
tion with  it,  it  is  quite  legitimate  to  make  an  attempt  to  place  the  cord 
beyond  the  reach  of  dangerous  pressure  by  other  methods.  Unfortu- 
nately, reposition  is  too  often  disappointing,  difficult  to  effect,  and  very 
fi'equently,  even  when  apparently  successful,  shortly  followed  by  a  fresh 
descent  of  the  cord.  Provided  the  os  be  fully  dilated  and  the  presenting 
head  engaged  in  the  pelvis  (for  reposition  may  be  said  to  be  hopeless 
when  any  other  part  presents),  perhaps  the  best  way  is  to  attempt  it  by 
the  hand  alone.  Probably  the  simplest  and  most  effectual  method  is  that 
recommended  by  McClintock  and  Hardy,  who  advise  that  the  patient 
should  lie  on  the  opposite  side  to  the  prolapsed  cord,  which  should  then 
be  drawn  toward  the  pubes  as  being  the  shallowest  part  of  the  pelvis. 
Two  or  three  fingers  may  then  be  used  to  push  the  cord  jDast  the  head 
and  as  high  as  they  can  reach.  They  must  be  kept  in  the  pelvis  until  a 
pain  comes  on,  and  then  very  gently  withdrawn,  in  the  hope  that  the 
cord  may  not  again  prolapse.  During  the  pain  external  pressure  may 
very  properly  be  applied  to  favor  descent  of  the  head.  This  manoeuvre 
may  be  repeated  during  several  successive  pains,  and  may  eventually 
succeed.  The  attempt  to  hook  the  cord  over  the  foetal  limbs  or  to  place 
it  in  tlie  hollow  of  the  neck,  recommended  in  many  works,  involves  so 
dec])  an  introduction  of  the  hand  that  it  is  obviously  impracticable. 

indruments  Used  for  Reposition. — Various  complex  instruments  have 
been  invented  to  aid  reposition  (Fig.  123),  but  even  if  we  possessed  them 
they  are  not  likely  to  be  at  hand  when  the  emergency  arises.  A  simple 
instrument  may  be  improvised  out  of  an  ordinary  male  elastic  catheter 
by  passing  the  two  ends  of  a  piece  of  string  through  it,  so  as  to  leave  a 
loop  emerging  from  the  eye  of  the  catheter.  This  is  passed  through  the 
loop  of  ])rolapscd  cord,  and  then  fixed  in  the  eye  of  the  catheter  by 
means  oftlie  stilette.  The  cord  is  then  pushed  uj)  into  the  uterine  cavity 
by  the  catlieter,  and  liberated  by  withdrawing  the  stilette.  Another 
simple  instrument  may  be  made  by  cutting  a  hole  in  a  piece  of  whale- 
bone. A  piece  of  tapr;  is  then  passed  through  thci  loop  of  the  cord  and 
the  (!nds  threaded  throiigli  the  eye  cut  in  the  whalel)oiie.  liy  tightening 
tli(!  tnpe  the  whalebone  is  held  in  close  aj)|)osition  to  the  (!ord,  and  the 
whole  is  passed  as  high  .is  possible  int(j  the  uterine  cavity.     The  tape  can 


336 


LABOR. 


Fig.  123. 


easily  be  liberated  by  pulling  one  end.     If  preferred,  the  cord  can  be  tied 
to  the  whalebone,  which  is  left  in  utero  until  the  child  is  born.     Noth- 
ing need  be  said  as  to  the  various  other  methods  adopted  for  keeping  up 
the  cord,  such  as  the  insertion  of  pieces  of  sponge  or 
tying  the  cord  in  a  bag  of  soft  leather,  since  they  are 
generally  admitted  to  be  quite  useless. 

Treatment  ichen  Reposition  Fails. — It  only  too  often 
happens  that  all  endeavors  at  reposition  fail.  The 
subsequent  treatment  must  then  be  guided  by  the  cir- 
cumstances of  the  case.  If  the  pelvis  be  roomy  and 
the  pains  strong,  especially  in  a  multipara,  we  may 
often  deem  it  advisable  to  leave  the  case  to  nature,  in 
the  hope  that  the  head  may  be  pushed  through  before 
pressure  on  the  cord  has  had  time  to  prove  fatal  to  the 
child.  Under  such  circumstances  the  patient  should 
be  urged  to  bear  down,  and  the  descent  of  the  head 
promoted  by  uterine  pressure,  so  as  to  get  the  second 
stage  completed  as  soon  as  possible.  If  the  head  be 
within  easy  reach,  the  application  of  the  forceps  is 
quite  justifiable,  since  delay  must  necessarily  involve 
the  death  of  the  child.  During  this  time  the  cord 
should  be  placed,  if  possible,  opposite  one  or  other 
sa'cro-iliac  synchondrosis,  according  to  the  position  of 
the  head,  as  the  part  of  the  pelvis  where  there  is  the 
most  room,  and  where  the  pressure  would  consequently 
be  least  prejudicial.  If  we  have  to  do  with  a  case  in 
which  the  head  has  not  descended  into  the  pelvis,  and 
postural  treatment  and  reposition  have  both  failed,  pro- 
vided the  OS  be  fully  dilated  and  other  circumstances 
be  favorable,  turning  would  undoubtedly  offer  the  best 
chance  to  the  child.  This  treatment  is  strongly  advo- 
cated by  Engelmann,  Avho  found  that  70  per  cent,  of  the  children  delivered 
in  this  way  were  saved.  There  can  be  no  question  that,  so  far  as  the 
interests  of  the  child  are  concerned,  it  is,  under  the  circumstances  indi- 
cated, by  far  the  best  expedient.  Turning,  however,  is  by  no  means 
always  devoid  of  a  certain  risk  to  the  mother,  and  the  performance  of 
the  operation  in  any  particular  case  must  be  left  to  the  judgment  of  the 
practitioner.  A  fully-dilated  os,  with  membranes  unruptured,  so  that 
version  could  be  performed  by  the  combined  method  without  the  intro- 
duction of  the  hand  into  the  uterus,  would  be  unquestionably  the  most 
favorable  state.  If  it  be  not  deemed  proper  to  resort  to  it,  all  that  can 
be  done  is  to  endeavor  to  save  the  cord  from  pressure  as  much  as  possible 
by  one  or  other  of  the  methods  already  mentioned. 


Braun's   Apparatus  for 
Replacing  the  Cord. 


PROLONGED  AND  PRECIPITATE  LABORS.  ,337 


CHAPTER   IX. 

•  PKOLONGED  AND  PRECIPITATE  LABORS. 

Dystocia  arising  from  Defective  or  Irregular  Action  of  the  Uterus. — 
Among  the  difficulties  connected  with  parturition  there  are  none  of  more 
frequent  occurrence,  and  none  requiring  more  thorough  knowledge  of 
the  physiology  and  pathology  of  labor,  than  those  arising  from  deficient 
or  irregular  action  of  the  expulsive  powers.  The  importance  of  study- 
ing this  class  of  labors  will  be  seen  when  we  consider  the  numerous  and 
very  diverse  causes  which  produce  them. 

Evil  Effects  of  Prolonged  Labor. — That  the  mere  prolongation  of  labor 
is  in  itself  a  serious  thing  is  becoming  daily  more  and  more  an  acknow- 
ledged axiom  of  midwifery  practice ;  and  that  this  is  so  is  evident  when 
we  contrast  the  statistical  returns  of  such  institutions  as  the  Rotunda 
Lying-in  Hospital  of  late  years  with  those  which  were  published  some 
twenty  or  thirty  years  ago.  It  may  be  fairly  assumed  that  the  practice 
of  the  distinguished  heads  of  that  well-known  school  represents  the  most 
advanced  and  scientific  opinion  of  the  day.  When  we  find  that  less 
than  thirty  years  ago  the  forceps  were  not  used  more  than  once  in  310 
labors,  while,  according  to  the  report  for  1873,  the  late  Master  applied 
them  once  in  8  labors,  it  is  apparent  how  great  is  the  change  which  has 
taken  place. 

Causes^jf__Prolonged   Labor. — Labor    may  be    prolonged   from    an    ■ 
immense  number  of  causes,  the  principal  of  which  will  require  separate 
study.      Some  depend  simply  on  defective  or  irregular  action  of  the  OJ}^^r^w^ 
uterus ;  others  act  by  opposing  the  expulsion  of  the  child,  as,  for  exam-  Biavw**  \ 
pie,  undue  rigidity  of  the  parturient  passages,  tumors,  bony  deformity, 
and  the  like.     Whatever  the  source  of  delay,   a  train  of  formidable    IT 
symptoms  are  developed  which  are  fraught  with  peril  both  to  the  mother  ^-(XwC 
and  the  child.     As  regards  the  mother,  they  vary  much  in  degree  and  ^y^i*^^ 
in  the  rapidity  with  M^iich  they  become  established.     In  many  cases,  in    ^n  -^.^ 
which  the  action  of  the  uterus  is  slight,  it  may  be  long  before  serious      0 
results  follow ;    while  in  others,  in  which  a  strongly-acting  organ  is 
exhausting  itself  in  futile  endeavors  to  overcome  an  obstacle,  the  worst 
signs  of  protraction  may  come  on  with  comparative  rapidity. 

T/ui  Influence  of  the  Stage  of  Labor  in  Protraction. — The  stage  of 
labor  in  which  delay  occurs  has  a  marked  effect  in  the  production  of 
untoward  symptoms.     It  is  a  well-established  fact  that  prolongation  is  | 
of  comparatively  small  consequence  to  either  the  mother  or  child  in  the 
first  stage,  when  the  membranes  are  still  intact,  and  when  the  soft  parts  j 
of  the  motlier,  as  well  as  the  body  of  the  child,  are  protected  by  the  H<]-  i 
nor  aniiiii  from  injurious  pressure;  wliei'casjf  the  membranes  have  rup- 
tured, prolongation  be(!omes  of  the;  utmost  imj)ortance  to  both  as  soon  as 
tlie  head  has  entered  the  ])elvis,  when  the  uterus  is  strongly  excited  by 
reflex  stimulation,  when  the  maternal  soft  parts  are  exposed  to  continu- 

22 


338  LABOR. 

ous  pressure,  and  when  the  tightly-contracted  uterus  presses  firmly  on 
the  foetus  and  obstructs  the  placental  circulation.  It  is  in  reference  to 
the  latter  class  of  cases  that  the  change  of  practice  already  alluded  to 
has  taken  place,  with  the  most  beneficial  results  both  to  the  mother  and 
child. 

It  must  not  be  assumed,  however,  that  prolongation  of  labor  is  never 
of  any  consequence  until  the  second  stage  has  commenced.  The  fallacy 
of  such  an  opinion  was  long  ago  shown  by  Simpson,  who  proved  in  the 
most  conclusive  way  that  both  the  maternal  and  foetal  mortality  were 
greatly  increased  in  proportion  to  the  entire  length  of  the  labor  ;  and  all 
practical  accoucheurs  are  familiar  with  cases  in  which  symptoms  of 
gravity  have  arisen  before  the  first  stage  is  concluded.  Still,  relatively 
speaking,  the  opinion  indicated  is  undoubtedly  correct. 

In  the  present  chapter  we  have  to  do  only  with  those  causes  of  delay 
connected  with  the  expulsive  powers.  Inasmuch,  however,  as  the 
injurious  effects  of  protraction  are  similar  in  kind,  whatever  be  the 
cause,  it  will  save  needless  repetition  if  we  consider,  once  for  all,  the 
train  of  symptoms  that  arise  whenever  labor  is  unduly  prolonged. 

Delay  in  the  First  Stage. — As  long  as  the  delay  is  in  the  first  stage 
only,  with  rare  exceptions  no  symptorns  of  real  gravity  arise  for  a  length 
ofjtime,  it  may  be  even  for  clays.  There  is  often,  however,  a  partial  ces- 
sation of  the  pains,  which  in  consequence  of  temporary  exhaustion  of 
nervous  force  may  even  entirely  disappear  for  many  consecutive  hours. 
Under  such  circumstances,  after  a  period  of  rest,  either  natural  or  pro- 
duced by  suitable  sedatives,  they  recur  with  renewed  vigor. 

Symptoms  of  Protraction  in  the  Second  Stage. — A  similar  temporary 
cessation  of  the  pains  may  often  be  observed  after  the  head  has  passed 
through  the  os  uteri,  to  be  also  followed  by  renewed  vigorous  action 
after  rest.  But  now  any  such  irregularity  must  be  much  more  anxiously 
watched.  In  the  majority  of  cases  any  marked  alteration  in  the  force 
and  frequency^of  the  pains  at  this  period  indicates  a  much  more  serious 
form  ofdelay^  which  in  no  long  time  is  accompanied  by  grave  general 
symptoms.  The  pulse  begins_to_rise,  the  skin  to  become  hot  and  drv, 
the  patient_to_bej;;estless_^^  The  longer  the  delay  and  the 

more  violent  the  efforts  of  the  uterus  to  overcome  the  obstacle,  the  more 
serious  does  the  state  of  the  patient  become.  The  tongue  is  loaded  with 
fiir,  and  in  the  worst  cases  dry  and  black ;  nausea  and  vomiting  often 
become  marked  ;  the  vagina  feels  hot  and  dry,  the  ordinary  abundant 
mucous_secretionj3ging  absent ;  in  severe  cases  it  may  be  much  swollen, 
and  if  the  presenting  part  be  firmly  impacted  a  slough  may  even  forni. 
ShoiiMthe_patien^  remain  undelivered,  all  these  symptoms  become 
greatlyTntensifiedT^  the  voniiting  is  incessant,  the  pulse  is  rapid  and 
almost  nnperceptible,  low  muttering  delirium  supervenes,  and  the  patient 
eventually  dies  with  all  the  worst  iiidications  of  profound  irritation  and 
exhaustion. 

So  formidable  a  train  of  symptoms,  or  even  the  slighter  degrees  of 
them,  should  never  occur  in  the  practice  of  the  skilled  obstetrician ;  and 
it  is  precisely  because  a  more  scientific  knowledge  of  the  process  of  par- 
turition has  taught  the  lesson  that  under  such  circumstances  prevention  is 
better  than  cure,  that  earlier  interference  has  become  so  much  more  the  rule. 


PROLONGED  AND  PRECIPITATE  LABORS.  339 

Those  who  taught  that  nothing  should  be  done  until  nature  had  had 
every  possible  chance  of  effecting  delivery,  and  who  therefore  allowed 
their  patients  to  drag  on  in  many  weary  hours  of  labor,  at  the  expense 
of  great  exhaustion  to  themselves  and  imminent  risk  to  their  offspring, 
made  much  capital  out  of  the  time-honored  maxim  that  "  Meddlesome 
midwifery  is  bad."  When  this  proverb  is  applied  to  restrain  the  rash 
interference  of  the  ignorant,  it  is  of  undeniable  value ;  but  when  it  is 
quoted  to  prevent  the  scientific  action  of  the  experienced,  who  know  pre- 
cisely when  and  why  to  interfere,  and  who  have  acquired  the  indispen- 
sable mechanical  skill,  it  is  sadly  misapplied. 

State  of  the  Uterus  in  Protracted  Labor. — The  nature  of  the  pains  and 
the  state  of  the  uterus  in  cases  of  protracted  labor  are  peculiarly  worthy 
of  study,  and  have  been  very  clearly  pointed  out  by  Dr.  Braxton 
Hicks.^  He  shows  that  when  the  pains  have  apparently  fallen  off  and 
become  few  and  feeble,  or  have  entirely  ceased,  the  uterus  is  in  a  state 
of  continuous  or  tonic  coiitraction,  and  that  the  irritation  resulting  from 
this  is  the  chief  cause  of  the  more  marked  symptoms  of  powerless  labor. ' 
If  in  a  case  of  the  kind  the  uterus  be  examined  by  palpation,  it  will  be 
found  firmly  contracted  between  the  pains.  The  correctness  of  this 
observation  is  beyond  question,  and  it  will  no  doubt  often  be  an  import- 
ant guide  in  treatment.  Under  such  circumstances  instrumental  inter- 
ference is  imperatively^lemanded. 

Conditions  and  Causes  affecting  the  Expulsive  Powers. — In  consider- 
ing the  causes  of  protracted  labor  it  will  be  well  first  to  discuss  those 
which  affect  the  expulsive  powers  alone,  leaving  those  depending  on 
morbid  states  of  the  passages  for  future  consideration ;  bearing  in  mind, 
however,  that  the  results,  as  regards  both  the  mother  and  the  child,  are 
identical,  whatever  may  be  the  cause  of  delay. 

Constitution  of  the  Patient. — The  general  constitutional  state  of  the 
patient  may  materially  influence  the  force  and  efficiency  of  the  pains. 
Thus,  it  not  unfrequently  happens  that  they  are  feeble  and  ineffective  in 
^yomen  of  very  weak  constitution  or  who  are  much  exhausted  by  debil- 
itating disease.  Cazeaux  pointed  out  that  the  effects  of  such  general 
conditions  are  often  more  than  counterbalanced  by  flaccidity  and  want 
of  resistance  of  the  tissues,  so  that  there  is  less  obstacle  to  the  passage 
of  the  child.  Thus,  in  phthisical  patients  reduced  to  the  last  stage  of 
exhaustion  labor  is  not  unfrequently  surprisingly  easy. 

Influence  of  Tropical  Climates. — TiOng_2;esWencejn_tTOpi^^ 
(■auses  uterine  inertia,  in  consequence  of  the  enfeebled  nervous  power  it 
produces.  It  is  a  common  observation  that  European  residents  in  India 
are  peculiarly  apt  to  suffer  from  post-partum  hemorrhage  from  this 
cause.  The  general  mode  of^  life  of  patients  has  an  unquestionable 
effect ;  and  it  is  certain  thsuTJeficieiit^ncniTegular  uterine  action  is  more 
cominon  in  women_Qf  the  liigher  ratiks  oTjocietyrA\jio  lead  luxurious, 
enervating  lives,  than  in  \vomcn  whose  habits  are  of  a  more  healthy 
character.  ~~      ~~ 

Frcfpient  Childhearing. — Tyler  Smith  lays  much  stress  on  frequent 
('hildl)earing  as  a  cause  of  inertia,  pointing  out  that  a  uterus  whi(;h  has 
been  very  frequently  subje(;ted  to  the  changes  connected  with  pregnancy 

'  Obat.  Trann.,  vol.  ix. 


340  LABOR. 

is  unlikely  to  be  in  a  typically  normal  condition.  It  is  doubtful,  how- 
ever, whether  the  uterus  of  a  perfectly  healthy  woman  is  affected  in  this 
way ;  certainly,  if  childbearing  had  undermined  her  general  health  the 
labors  are  likely  to  be  modified  also. 

Age  of  Patient. — Age  has  a  decided  effect.  In  the  very  young  the 
pains  are  apt  to  be  irregidar,  on  account  of  imperfect  development  of 
the  uterine  jnuscle.  Labor  taking  place  for  the  first  time  in  women 
adyanced  in  life  is  also^apMo  Jje^tedious^  but  not  by  any  means^ojnya- 
riably  as  is  generally  believed.  The  apprehensions  of  such  patients  are 
often  agreeably  falsified,  and  where  delay  does  occur  it  is  probably  more 
often  referable  to  rigidity  and  toughness  of  the  parturient  passages  than 
to  feebleness  of  the  pains. 

Disorders  of  the  Intestines. — Morbid  states  of  the  primse  vise  fre- 
quently cause  irregular,  painful,  and  feeble  contractions.  A  loaded 
state  of  the  rectum  has  a  remarkable  influence,  as  evidenced  bythe  sucl- 
den  and  distinct  change  in  the  character  of  the  labor  which  often  follows 
the  use  of  suitable  remedies.  Undue  distension  of  the  bladder  may  act 
in  the  same  way,  more  especially  in  the  second  stage.  When  the  urine 
has  been  allowed  to  accumulate  unduly,  the  contralfttion  of  the  accessory 
muscles  of  parturition  often  causes  such  intense  suffering,  by  compress- 
ing the  distended  viscus,  that  the  patient  is  absolutely  unable  to  bear 
down.  Hence  the  labor  is  carried  on  by  uterine  contractions  alone, 
slowly  and  at  the  expense  of  much  suffering.  A  similar  interference 
with_the  action  of  the  accessory  muscles  is  oftenjjixxluced  by  other 
causes.  Thus,  if  labor  comes  on  when  the  patient  is  suffering  from 
bronchitis  or  otlier  chest  disease,  she  may  be  quite  unable  to  fix  the  chest 
by  a  deep  inspiration,  andlilie  diaphragm  and  other  accessory  muscles 
cannot  act.  In  the  same  way  they  may  be  pre vented_ from  acting  when 
the  aJDdomen_^sjX!Cupi^^ 

Mental  conditions  have  a  very  marked  effect.  This  is  so  commonly 
observed  that  it  is  familiar  to  the  merest  beginner  in  midwifery  practice. 
The  fact  that  the  pains  often  diminish  temporarily  on  the  entrance  of 
the  accoucheur  is  known  to  every  nurse ;  and  so  also  undue  excitement, 
the  presence  of  too  many  people  in  the  room,  overmuch  talking,  have 
often  the  same  prejudicial  effect.  Depression  of  mind,  as  in  unmarried 
women,  and  fear  and  despondency  in  women  whohave  looked  forward 
with  apprehension  to  their  labor,  are  also  common  causes  of  irregular 
and  defective  action. 

Excessive  Amount  of  Liquor  Amnii. — Undue  distension  of  the  uterus 
from  an  excessive  amount  of  liquor  amnii  not  unfrequently  retards  the 
first  stage  by  preventing  the  uterus  from  contracting  efficiently.  When 
tliis  exists,  the  pjmisare_feeble  and  have  little  effect  in  dilating  the  cer^ 
vix  bc^'on(^_ceritaiii[cIi^?6^-  This  cause  may  be  suspected  when  undue 
protraction  of  the  first  stage  jsjissociated  with  an  unusually  large  size 
and  niarked  fluctuation  of  the  uterine  tumor,  througli  jvhich  the  foetal 
linibs^  cannot  Jjfi  made.  mit-Qii  palpation.  On  vaginal  examination  the 
lower^egment  of  the  uterus  will  be  found  to  be  very  rounded  and  prom- 
inent, while  the  bag  of  menibranes  \vill_not  bulge  through  the  os  during 
the  acme  of  jtlie  pain. 

IlalpomMons'of  the  Uterus. — A  somewhat  similar  cause  is  undue  ob- 


PROLONGED  AND  PRECIPITATE  LABORS.  341 

lig[uity  of  the  uterus,  which  prevents  the  pains  acting  to  the  best  mechan- 
ical advantage  and  often  retards  the  entry  of  the  presenting  part  into  the  i    'z. 
brim.     The  most  common  variety  is  anteversipn,  resuking  from  undue  h^^-^^^^f^ 
laxity  of  the  abdominal  parietes,  which  is  especially  found  in  women 
who  have  borne  many  children.     Sometimes  this  is  so  excessive  that  the 
fundus  lies  over  the  pubes,  and  even  projects  downward  toward  the 
patient's  knees.     The  consequence  is,  that  when  labor  sets  in,  unless  cor- 
rective means  be  taken,  the  pains  force  the  head  against  the  sacrum, 
instead  of  directing  it  into  the  axis  of  the  pelvic  inlet.     Another  com-  XiaLU  s6*' 
rnon  deviation  is  lateral  obliquity,  a  certain  degree  of  which  exists  in       ~~— 
almost  all  cases,  but  sometimes  it  occurs  to  an  excessive  degree.     Either 
of  these  states  can  readily  be  detected  by  palpation  and  vaginal  examina- 
tion combined.     In  the  former  the  os  may  be  so  high  up  and  tilted  so 
far  backward  that  it  may  be  at  first  difficult  to  reach  it  at  all. 

Irregular  and  Spasmodic  Pains. — Besides  being  feeble,  the  uterine 
contractions,  especially  in  the  first  stage,  are  often  irregular  and  spas- 
modic, intensely  painful,  but  producing  little  or  no  effect  on  the  progress 
of  the  labor.  This  kind  of  case  has  been  already  alluded  to  in  treating 
of  the  use  of  anaesthetics  (p.  295),  and  is  very  common  in  highly-nervous 
and  emotional  jwomen  of  the  upper  classes.  Such  irregular  contractions 
do  not  necessarily  depend  on  mental  causes  alone,  and  they  are  often 
produced  by  conditions  producing  irritation,  such  as  loaded  bowels,  too 
early  rupture  of  the  membranes,  and  the  like.  Dr.  Trenholme  of  Mon- 
treal^ believes  that  such  irregular  pains  most  frequently  depend  on 
abnormal  adhesions  between  the  clecidua  and  the  uterine_walls,  which 
interfere  with  the  proper  dilatation  of  the  os,  and  he  has  related  some 
interesting  cases  in  support  of  this  theory. 

Treatment. — The  mere  enumeration  of  these  various  causes  of  protracted 
labor  will  indicate  the  treatment  required.  Some  of  them,  such  as  the 
constitutional  state  of  the  patient,  age,  or  mental  emotion,  it  is  of  course 
beyond  the  power  of  the  practitioner  to  influence  or  modify ;  but  in 
every  case  of  feeble  or  irregular  uterine  action  a  careful  investigation 
should  be  made  with  a  view  of  seeing  if  any  removable  cause  exist. 
For  example,  the  effect  of  a  large  enema  when  we  suspect  the  existence 
of  a  loaded  rectum  is  often  very  remarkable,  the  pains  frequently  almost 
immediately  changing  in  character  and  a  previously  lingering  labor 
being  rapidly  terminated. 

Excessive  distension  of  the  uterus  can  only  be  treated  by  artificial  evac- 
uation of  the_liquor  amnii ;  and  after  this  is  done  the  character  of  the 
pains  often  rapidly  changes.  This  expedient  is  indeed  often  of  consider- 
able value  in  cases  in  which  the  cervix  has  dilated  to  a  certain  extent, 
but  in  which  no  further  progress  is  made,  especially  if  the  bag  of  mem- 
bi'anes  does  not  protrude  through  the  os  during  the  pains,  and  the  cer- 
vix itself  is  soft  and  a[)parently  readily  dilatable.  Under  such  circum- 
stances rupture  of  the  menibrancs,  evea  before  the  os  is  fully  dilated,  is 
often  very  useful. 

Adherent  Membranes. — If  we  have  reason  to  suspect  morbid  aclhe- 
■sions  between  tlie  membranes  and  the  uterine  walls,  an  endeayor  must  be 
made  to^separate  tlieni  by  sweeping  the  finger  or  a  flexible  catheter  round 

»  Obnt.  Tram.,  187?. 


342  LABOR.  • 

the  internal  marginj)f  the  os  orjjimcturing  the  sac.  The  former  expedi- 
ent hiislbeen^Svwiated  by  Dr.  Inglis^  as  a  means  of  increasing  the  pains 
when  the  first  stage  is  very  tedious,  and  I  liave  often  practised  it  with 
marked  success.  Trenholme's  observation  affords  a  rationale  of  its 
action.  The  manoeuvre  itself  is  easily  accomplished,  and,  provided  the 
OS  be  not  very  high  in  the  pelvis,  does  not  give  any  pain  or  discomfort 
to  the  patient. 

Uterine  Deviations. — Attention  should  always  be  paid  to  remedying 
any  deviations  of  the  uterus  from  its  proper  axis.  If  this  be  lateral, 
the  proper  course  to  pursue  is  to  make  the  patient  lie  on  the  opposite 
side  to  that  toward  which  the  organ  is  pointing.  In  the  more  common 
anterior  deviation  she  should  lie  ojo^her  back,  so  that  the  uterus  may 
gravitate  toward  the  spine,  and  a  firm  abdominal  bandage  should  be 
applied.  This  prevents  the  organ  from  falling  forward,  while  its  pres- 
sure stinmlatesj^iejnuscular  fibres  to  mcreasecl  action ;  hence  it  is  often 
very  serviceable^vvEeirthe^ins  areleeble,  even  if  there  be  no  anteversion. 

Temjiorary  Exhaustion. — In  a  frequent  class  of  cases,  especially  in  the 
first  stage,  the  pains  diminish  in  force  and  frequency  from  fatio;ue,  and 
the  indication_then  isjto  give  a  temporaixilgst,  after  which  they  recom- 
mence with  renewed  vigor.  Hence  an  opiate,  such  as  20  minipas  of 
Battley's  solution,  which  often  acts  quickest  when  given  in  the  form 
of  enema,  is  frequently  of  the  greatest  possible  value.  If  this  secure  a 
few  hours'  sleep,  the  patient  will  generally  awake  much  refreshed  and 
invigorated.  It  is  important  to  distinguish  this  variety  of  arrested^ain 
from  that  clependgnt  on  actual  exhaustion ;  and  this  can  be  done  by 
attention^  to  the  general  condition  of^  the  patient,  and  especially  by 
observing  that  theuterus  is  soft  and  flaccid  in  the  intervals  between  the 
pains,  and  that  there  is  none  of  the  tonic  contraction  indicated  by  per- 
sistent hardness  of  the  uterine  parietes.  When  the  ]3ains  are  irregular, 
spasmodic,  and  excessively  painful  withoul_piotlucing  anxjlgal  effect, 
opiates^  are  also  of  greSt^ervice ;  and  it  is  under  such  circumstancesthat 
chloral  is  especially  valuable. 

Oxytocic  Remedies. — Still,  a  large  number  of  cases  will  arise  in  which 
the  absence  of  all  removable  causes  has  been  ascertained  and  in  which 
the  pains  are  feeble  and  ineffective.  We  must  now  proceed  to  discuss 
their  management.  The  fault  being  the  want  of  sufficient  contraction,  the 
first  indication  is  to  increase  the  force  of  the  pains.  Here  the  so-called 
o^rT^focicjremedies  come  into  action ;  and  although  a  large  number  of 
these  have  been  used  from  time  to  time,  such  as  borax,  cinnamon,  qui- 
nine, and  galvanism,  practically  the  only  one  on  which  reliance  is  gener- 
ally placed  is  the_ergot_ofj;ye. 

Urgot  of  Bye. — This  has  long  been  the  favorite  remedy  for  deficient 
uterine  action,  and  it  is^j30werful_stimulant  of  the  uterine^  fibres.  It 
has,  however,  very  serious  disadvantages,  and  it  is  very  questionable 
whether  the  risks  to  both  mother  and  child  do  not  more  than  counter- 
balance any  advantages  attending  its  use.  The  ergot  is  given  in  doses 
of  15_or^0_grains  of  the  freshly-powdered  drug  infused  in  warm  water, 
or  in  the  more  convenient  form  of  the  Ijquid^extract  in  doses  of  from  20 
to  30  minims,  or,  still  better,  in  the  form  of  ergotin  injected  hypodermic- 

^  Sydenham  Society's  Year-Book,  1869. 


PROLONGED  AND  PRECIPITATE  LABORS.  343 

ally,  3  to  4  minims  of  the  hypodermic  solution  being  used  for  the  pur- 
pose] TiTabout  fiTteen  minutes  after  it_s  administration  the  pains  gener- 
ally increase  greatly  in  force  and  frequency,  and  if  the  head  be  low  in 
the  pelvis,  and  if  the  soft  parts  offer  no  resistance,  the  labor  may  be 
rapidly  terminated. 

Objections  to  its  Use. — Were  its  use  always  followed  by  this  effect  there 
would  be  little  or  no  objection  to  its  administration.  The  pains,  how- 
ever, are  different  from  those  of  natural  labor,  being  strong,  persistent, 
and  constant.  Its_e£fect,  indeed,  is  to  produce  that  very  state  of  tonic 
and  persistent  uterine^contractjon  which  has  been  already  pointed  out  as 
one  of  the  chief  dangers  of  protracted  labor.  Hence,  if,  from  any  cause, 
the  exhjMtionjjfjthejhr^  rapid  delivery,  a  condition 

is  produced_which  is  serious  to  the  mother,  and  which  is  extremely  peril- 
ous to_the  chijd,  on  account  of  the  tonic  contraction  of  the  muscular 
fibres  obstructing  the  uterQ^placental  circulation.  Dr.  Hardy  found  that 
soon  the  foetal  pulsations  fall  to  100,  and  if  delivery  be  long  delayed 
they  commence  to  intermit.  He  also  observed  that  when  this  occurred 
the  child  was  always  born  dead,  and  found  that  the  number  of  stillborn 
children  after  ergot  has  been  exhibited  was  very  large,  for  out  of  30 
cases  in  which  he  gave  it  in  tedious  labor,  only  10  of  the  children  were 
born  alive.  IS^or  is  its  use  by  any  means  free  from  any  danger  to  the 
mother :  a  not  inconsiderable  number  of  cases  of  rupture  of  the  uterus 
have  been  attributed  to  its  incautious  use.  Hence,  if  it  is  to  be  given 
at  all,  it  is  obvious  that  it  must  be  with  strict  limitations  and  after  care- 
ful consideration.  It  is  worthy  of  note  that  in  the  Rotunda  Hospital 
in  Dublin  the  use  of  ergot  as  an  oxytocic  before  delivery  has  been  pro- 
hibited by  the  present  Master. 

Limitations  to  its  Use. — The  cardinal  point  to  remember  is,  that  it  is 
absolutely  contraindicated  unless  the  absence  of  all  obstacles  to  rapid 
delivery  has  been  ascertained.  Hence,  it  is  only  allowable  when_the 
first_slage_is_over  aiid  the  os  fully  dilated  ;  when  the  experience  of  for- 
mer labors  has  proved  the  pelvis  to  be  of  ample  size ;  and  when  the 
perineum  is  soft  and  dilatable.  Perhaps,  as  lias  been  suggested,  the 
administration  of  small  doses  of  from  5  to  10  minims  of  the  liquid 
extract  every  ten  minutes  until  more  energetic  action  set  in  might  obvi- 
ate some  of  these  risks. 

Quinine  as  an  Oxytoeie. — The  use  of  quinine  as  an  oxytocic  deserves 
much  more  attention  than  it  has  generally  received.  I  frequently  employ 
it  in  lingering  labor  with  marked  benefit,  and  it  does  not  seem  to  have  any 
of  the  Ijad  effects  of  ergot.  According  to  the  observations  of  Dr.  Albert 
H.  Smith,  in  42  cases  of  parturition  it  presented  the  following  peculiar 
characteristics  : 

It  has  no  power  in  itself_to_excite  uterine  contractions,  but  smiply 
actsjis  a  general  stimulant  and  promoter  of  vitaTenergy  and  functional 
activity. 

In  normal  labor  at  full  term  its  axlmmjstration^ iji^ 
is  usually  followed  in  as  many  minutes  by  a  decided  increase  in  the  force 
and   fVcquciKy  of  the  utei'ine  contractions,  changing  in  some  instances  a 
tedious,  exhausting  labor  into  one  of  rai)id  energy,  advancing  to  an  early 
completion. 


344  LABOR. 

It  promotes  the  permanent  tonic  contraction  of  the  uterus^fter  the 
expulsion  of  the  placeirta,  women  that  had  flooded  in  former  labors  escap- 
ing entirely,  there  not  having  been  an  instance  of  post-partum  hemorrhage 
in  the  whole  42  cases. 

It  also  diminishes  the  lochial  flow  where  it  had  been  excessive  in  for- 
mer laborsTthechange  being  reniarked  upon  by  the  patients,  and  conse- 
quently lessens  the  severity  of  the  after-pains. 

Cinchonism  is  very  rarely  observed  as  an  effect  of  large  doses  in  par- 
turient women. ^ 

Use  of  the  FaracUc  Current. — The  faradic  current  applied  on  either 
side  of  the  uterine  tumor,  midway  between  the  anterior-superior  spine 
of  the  ilium  and  the  umbilicus,  has  recently  been  strongly  recommended 
by  Dr.  Kilner,^  not  only  as  a  means  of  increasing  uterine  action,  but  of 
alleviating  the  sufferings  of  childbirth.  I  have  tried  it  in  several  cases, 
but  am  not  satisfied  as  to  its  possessing  the  properties  attributed  to  it. 

Manual  Pressure  as  a  Means  of  Increasing  the  Uterine  Contractions. — 
If  we  had  no  other  means  of  increasing  defective  uterine  contractions  at 
our  disposal,  and  if  the  choice  lay  only  between  the  use  of  ergot  and 
instrumental  delivery,  there  might  not  be  so  much  objection  to  a  cau- 
tious use  of  the  drug  in  suitable  cases.  We  have,  however,  a  means  of 
increasing  the  force  of  the  uterine  contractions  so  much  more  manage- 
able and  so  much  more  resembling  the  natural  process  that  I  believe  it 
to  be  destined  to  entirely  supersede  the  administration  of  ergot.  This 
is  the  application  of  manual  pressure  to  the  uterus  through  the  abdo- 
men: — an  expedient  that  has  of  late  years  been  much  used  in  Germany, 
and  has  begun  to  be  employed  in  English  practice.  I  believe,  therefore, 
that  ergot^should  be  chiefly  used  for  the  purpose  of  exciting  uterine  con- 
traction after  delivery,  when  its  peculiar  property  of  promoting  tonic 
contraction  is  so  valuable,  and  that  it  should  rarely,  if  at  all,  be  employed 
before_dieJ}irth_^f_the_chi^ 

The  systematic  use  of  uterine  pressure  as  an  oxytocic  was  first  promi- 
nently brought  under  the  notice  of  the  profession  by  Kristeller  under 
the  name  of  "  Expressio  Foetus,"  although  it  has  been  used  in  various 
forms  from  time  immemorial.  Albucasis,  for  example,  was  clearly 
acc{uainted  with  its  use,  and  referred  to  it  in  the  following  terms :  "  Cum 
ergovides  istasigna,  tunc  oportet,  ut  comprimatur  uterus  ejus  ut  descendat 
embryo  velociter."  There  are  some  curious  obstetric  customs  among  vari- 
ous nations  which  probably  arose  from  a  recognition  of  its  value ;  as, 
for  example,  the  mode  of  delivery  adopted  among  the  Kalmucks,  where 
the  patient  sits  at  the  foot  of  the  bed,  while  a  woman  seated  behind  her 
seizes  her  round  the  waist  and  squeezes  the  uterus  during  the  pains. 
Amongst  the  Japanese,  Siamese,  North  American  Indians,  and  many 
other  nations  pressure,  applied  in  various  ways,  is  habitually  used. 

Kristeller  maintains  that  it  is  possible  to  effect  the  complete  expulsion 
of  the  child  by  properly-applied  pressure,  even  when  the  pains  are 
entirely  absent.  Strange  as  this  may  appear  to  those  who  are  not  familiar 
with  the  effects  of  pressure,  I  believe  that  under  exceptional  circum- 
stances, when  the  pelvis  is  very  capacious  and  the  soft  parts  offer  but 
slight  resistance,  it  can  be  done.     I  have  delivered  in  this  ^^•ay  a  patient 

1  T/•r(?(^^  Coll.  Physi.  Philada.,  1875,  p.  183.  =  Lancet,  .January  1,  1881. 


PROLONGED  AND  PRECIPITATE  LABORS.  345 

whose  friends  would  not  permit  me  to  apply  the  forceps  when  I  could 
not  recognize  the  existence  of  any  uterine  contraction  at  all,  the  foetus 
being  literally  squeezed  out  of  the  uterus.  ItjsjiotjJio;vv:ever,_as_repla- 
cing  absent  pains,  but  as  a  means  of  intensifying  and  prolonging  the 
effects  of  .deflcient  and  feeble  ones,  that  pressure  finds  its^best  applicatimi- 

Its  effects  are  often  very  remarkable,  especially  in  women  of  slight 
build  where  there  is  but  little  adipose  tissue  in  the  abdominal  walls  and 
not  much  resistance  in  the  pelvic  tissues.  If  the  finger  be  placed  on  the 
head  while  pressure  is  applied  to  the  uterus,  a  very  marked  descent  can 
readily  be  felt,  and  not  infrequently  two  or  three  applications  will  force 
the  head  on  to  the  perineum.  There  are,  however,  certain  conditions 
when  it  is  inapplicable,  and  the  existence  of  which  should  contrainclicate 
its  use.  Thus,  if  the  uterus  seem  unusually  tender  on  pressure,  and, 
~a  Jortiojn,  if  the  tonic  contraction  of  exhaustion  be  present,  it  is  inad- 
missible. So  also  if  there  be  any  obstruction  to  rapid  delivery,  either 
from  narro^^dng  of  the  pelvis  or  rigidity  of  the  soft  parts,  it  should  not 
be  used.  The  cases  suitable  for  its  application  are  those  in  which  the 
head  or  breech  is  in  the  pelvic  cavity,  and  the  delay  is  simply  due  to  a 
want  of  sufficiently  strong  expulsive  action. 

Mode  of  Application. — It  may  be  applied  in  two  ways.  The  better 
is  to  place  the  patient  on  her  back  at  the  edge  of  the  bed,  and  spread  the 
palms  of  the  hands  on  either_side  of  jlie_ftmdus  and  body  of  the  uterus, 
and  when _a  paiu_commences  to  make  firm  pressure^IuHng  its  continu- 
ance^ownward  and  backwardjn, the  direction  of  the  pelvic  inlet.  As 
the  contraction  passes  off  the  pre^ure  is  relaxed,  and  again  resumed 
when  a  fresh  pain  begins.  In  this  way  ^ach  pain  is  greatly  intensified 
and  its  eff'ect^on  the  progress  of  the  ^foetus  much  increased^  It  is  not 
essential  that  the  p^ientjhould  lie  on  her  back.  A  useful  although  not 
se  great  amount  of  pressure  can  be  applied  when  she  is  lying  in  the 
ordinary  obstetric  position  on  her  left  side,  the  left  hand  being  spread 
out  over  the  fundus,  leaving  the  right  free  to  watch  the  progress  of  the 
presenting  part  per  vagi  nam. 

Special  Value  of  Uterine  Pressure. — The  special  value  of  this  method 
of  treating  ineffective  pains  is,  that  the  amount  and  frequency  of  the 
pressure  are  completely  within  the  control  of  the  practitioner,  and  are 
capable  of  being  regulated  to  a  nicety  in  accordance  with  the  require- 
ments of  each  particular  case.  It  has  the  peculiar  advantage  of  closely 
imitating  the  natural  means  of  delivery,  and  of  being  absolutely  without 
risk  to  the  child  ;  nor  is  there  any  reason  to  think  that  it  is  capable  of 
injuring  the  mother.  At  least  I  may  safely  say  that,  out  of  the  large 
iiiiiiil)er  of  cases  in  which  I  liave  used  it,  I  have  never  seen  one  in 
wliich  I  had  the  least  reason  to  think  that  it  had  proved  hurtful.  Of 
course  it  is  essential  not  to  use  undue  roughness  :  firm  and  even  strong 
pressure  may  be  employed,  but  that  can  be  done  witliout  being  rough ; 
and,  as  its  application  is  always  intermittent,  there  is  no  time  for  it  to 
infii(,'t  any  injury  on  the  uterine  tissues. 

Pressure  is  sjx!cia]ly_va1ual)lc  \vh<^ILiiJ^-_flesjrablc_tiiJnteiisify  fi^^ 
jmins.  It  may  Ik;  s(!rvic(al)Iy  employed  when  the  ])ains  are  altogether 
absent  to  imitate  and  rei)]ace  tliciu,  ])rovidc(l  there  ho,  nothing  but  die 
absence  of  a  vh  a  terr/o  to  prevent  speedy  deb' very.     In  such  cases  an 


346  LABOR. 

endeavor  should  be  made  to  imitate  the  pains  as  closely  as  possible  by 
applying  the  pressure  at  intervals  of  four  or  five  minutes,  and  entirely 
relaxing  it  after  it  has  been  applied  for  a  few  seconds. 

Change  of  Professional  Opinion  as  to  Instrumental  Delivery. — When 
all  these  means  fail,  we  have  then  left  the  resource  of  instrumental  aid  ; 
and  we  have  now  to  consider  the  indications  for  the  use  of  the  forceps 
under  such  circumstances.  It  has  been  already  pointed  out  that  pro- 
fessional opinion  on  this  point  has  been  undergoing  a  marked  change, 
and  that  it  is  now  recognized  as  an  axiom  by  the  most  experienced 
teachers  that  when  we  are  once  convinced  that  the  natural  efforts  are 
failing  and  are  unlikely  to  effect  delivery,  except  at  the  cost  of  long 
delay,  it  is  far  better  to  interfere  soon  rather  than  late,  and  thus  prevent 
the  occurrence  of  the  serious  symptoms  accompanying  protracted  labor. 
The  recent  important  debate  on  the  use  of  the  forceps  at  the  Obstetrical 
Society  of  London  remarkably  illustrated  these  statements,  for,  while 
there  was  much  difference  of  opinion  as  to  the  advisability  of  applying 
the  forceps  when  the  head  was  high  in  the  j^elvis,  a  class  of  cases  not 
now  under  consideration,  it  was  very  generally  admitted  that  the  modern 
teaching  was  based  on  correct  scientific  grounds.  This  is,  of  course, 
directly  opposed  to  the  view  so  long  taught  in  our  standard  works,  in 
which  instrumental  interference  was  strictly  prohibited  unless  all  hope 
of  natural  delivery  was  at  an  end,  and  in  which  the  commencement  at 
least,  if  not  the  complete  establishment,  of  symptoms  of  exhaustion  was 
considered  to  be  the  only  justification  for  the  application  of  the  forceps 
in  lingering  labor. 

Vieivs  of  Dr.  Johnston  on  the  Use  of  the  Forceps. — The  reasons  which 
have  led  the  late  distinguished  Master  of  the  Rotunda  Hospital  to  a 
more  frequent  use  of  the  forcejjs  are  so  well  expressed  in  his  report  for 
1872  that  I  venture  to  quote  them  as  the  best  justification  for  a  practice 
that  many  practitioners  of  the  older  school  will,  no  doubt,  be  inclined 
to  condemn  as  rash  and  hazardous.  He  says  :  ^  "  Our  established  rule 
is,  that  so  long  as  nature  is  able  to  effect  its  purpose  without  prejudice 
to  the  constitution  of  the  patient,  danger  to  the  soft  parts  or  the  life  of 
the  child,  we  are  in  duty  bound  to  allow  the  labor  to  proceed  ;  but  as 
soon  as  we  find  the  natural  efforts  are  beginning  to  fail,  and  after  having 
tried  the  milder  means  for  relaxing  the  parts  or  stimulating  the  uterus 
to  increased  action,  and  the  desired  effects  not  being  produced,  we  con- 
sider we  are  in  duty  bound  to  adopt  still  prompter  measures,  and  by  our 
timely  assistance  relieve  the  sufferer  from  her  distress  and  her  offsjiring 
from  an  imminent  death.  Why,  may  I  ask,  should  we  permit  a  fellow- 
creature  to  undergo  hours  of  torture  when  we  have  the  means  of  reliev- 
ing her  within  our  reach  ?  Why  should  she  be  allowed  to  waste  her 
strength  and  incur  the  risks  consequent  upon  long  pressure  of  the  head 
on  the  soft  parts,  the  tendency  to  inflammation  and  sloughing,  or  the 
danger  of  rupture,  not  to  speak  of  the  poisonous  miasm  which  emanates 
from  an  inflanmiatory  state  of  the  passages,  the  result  of  tedious  labor, 
and  which  is  one  of  the  fertile  causes  of  puerperal  fever  and  all  its  dire- 
ful effects,  attributed  by  some  to  the  influence  of  being  confined  in  a 
large  maternity,  and  not  to  its  proper  source — i.  e.  the  labor  being 
^  Fourth  Clinical  Report  of  the  Rotunda  Lying-in  Hospital  for  the  year  ending  1872. 


PROLONGED  AND  PRECIPITATE  LABORS.  347 

allowed  to  continue  till  inflammatory  symptoms  appear  ?  The  more  we 
consider  the  benefits  of  timely  interference  and  the  good  results  which 
follow  it,  the  more  are  we  induced  to  pursue  the  system  we  have 
adopted,  and  to  inculcate  to  those  we  are  instructing  the  advantages 
to  be  gained  by  such  practice,  both  in  saving  the  life  of  the  child  as 
well  as  securing  the  greater  safety  of  the  mother."  It  would  be 
impossible  to  put  the  matter  in  a  stronger  or  clearer  light,  and  I  feel 
confident  that  these  views  will  be  endorsed  by  all  who  have  adopted  the 
more  modern  practice. 

Effect  of  Early  Interference  on  Infantile  Mortality. — In  the  first  edition 
of  this  work  I  used  the  statistics  of  Dr.  Hamilton  of  Falkirk  and  other 
modern  writers,  as  proving  that  a  more  frequent  use  of  the  forceps  than 
had  been  customary  diminished  in  a  remarkable  degree  the  infantile 
mortality.  Dr.  Galabin  ^  has  recently  published  an  admirable  paper  on 
this  subject,  in  which,  by  a  careful  criticism  of  these  figures,  he  has,  I 
think,  proved  that  the  conclusions  drawn  from  them  are  open  to  doubt, 
and  that  the  saving  of  infantile  life  following  more  frequent  forceps 
delivery  is  by  no  means  so  great  as  I  had  supposed.  Dr.  Roper,  in  his 
remarks  in  the  recent  debate  in  the  Obstetrical  Society,  brought  forward 
some  strong  arguments  in  support  of  the  same  view.  This,  however, 
does  not  in  any  way  touch  the  main  points  at  issue  referred  to  in  the 
preceding  paragraph. 

Possible  Dangers  attending  the  Use  of  the  Forceps. — It  is,  of  course, 
right  that  we  should  consider  the  opposite  point  of  view,  and  reflect  on 
the  disadvantages  which  may  attend  the  interference  advocated.  Here 
I  should  point  out  that  I  am  now  talking  only  of  the  use  of  the  forceps 
in  simple  inertia,  when  the  head  is  low  in  the  pelvic  cavity,  and  when 
all  that  is  wanted  is  a  slight  vis  a  fronte  to  supplement  the  deficient  vis 
a  tergo.  The  use  of  the  instrument  when  the  head  is  arrested  high  in 
the  pelvis,  or  in  cases  of  deformity,  or  before  the  os  uteri  is  completely 
expanded,  is  an  entirely  diflferent  and  much  more  serious  matter,  and 
does  not  enter  into  the  present  discussion.  The  chief  question  to  decide 
is  if  there  be  sufficient  risk  to  the  mother  to  counterbalance  that  of 
delay.  It  will,  of  course,  be  conceded  by  all  that  the  forceps  in  the 
hands  of  a  coarse,  bungling,  and  ignorant  practitioner,  who  has  not 
studied  the  proper  mode  of  operating,  may  easily  inflict  serious  damage. 
The  possibility  of  inflicting  injury  in  this  way  should  act  as  a  warning 
to  every  obstetrician  to  make  himself  thoroughly  acquainted  with  the 
proper  mode  of  using  the  instrument,  and  to  acquire  the  manual  skill 
which  practice  and  the  study  of  the  mechanism  of  delivery  will  alone 
give ;  but  it  can  hardly  be  used  as  an  argument  against  its  use.  If  that 
were  admitted,  surgical  interference  of  any  kind  would  be  tabooed,  since 
there  is  none  that  ignorance  and  incapacity  might  not  render  dangerous. 

AsHumiug,  therefore,  that  the  jiractitioner  is  able  to  apply  the  forceps 
skilfully,  is  there  any  inherent  danger  in  its  use?  I  think  all  who  dis- 
passionately consider  the  question  must  admit  that  in  the  class  of  cases 
alluded  to  the  operation  is  so  simple  that  its  disadvantages  cannot  for  a 
moment  be  weighed  against  those  attending  })roti-a(;tion  and  its  conse- 
quences.    Against  this  conclusion  statistics  may  ])()ssibly  be  quoted,  such 

^  Obstetrical  Journal,  Ueceniber,  1877. 


348  LABOR. 

as  those  of  Churchill,  who  estimated  that  1  in  20  mothers  delivered  by- 
forceps  in  British  practice  was  lost.  But  the  fallacy  of  such  figures  is 
apparent  on  the  slightest  consideration,  and  by  no  one  has  this  been 
more  conclusively  shown  than  by  Drs.  Hicks  and  Phillips  in  their  pai)er 
on  tables  of  mortality  after  obstetric  operations,^  where  it  is  proved  in 
the  clearest  manner  that  such  results  are  due  not  to  the  treatment,  but 
r,ather  to  the  fact  that  the  treatment  was  so  long  delayed. 

Impossibility  of  Laying  doivn  any  Definite  Rules  for  the  Use  of  the 
Forceps. — It  is  quite  impossible  to  lay  down  any  precise  rule  as  to  when 
the  forceps  should  be  used  in  uterine  inertia.  Each  case  must  be  treated 
on  its  own  merits  and  after  a  careful  estimate  of  the  effects  of  the  pains. 
The  rules  generally  taught  were  that  the  head  should  be  allowed  to  rest 
at  or  near  the  perineum  for  a  number  of  hours,  and  that  interference 
was  contraindicatecl  if  the  slightest  progress  were  being  made.  It  is 
needless  to  say  that  both  of  these  rules  are  incompatible  with  the  views 
I  have  been  inculcating,  and  that  any  rule  based  upon  the  length  of 
time  the  second  stage  of  labor  has  lasted  must  necessarily  be  misleading. 
What  has  to  be  done,  I  conceive,  is  to  watch  the  progress  of  the  case 
anxiously  after  the  second  stage  has  fairly  commenced,  and  to  be  guided 
by  an  estimate  of  the  advance  that  is  being  made  and  the  character  of 
the  pains,  bearing  in  mind  that  the  risk  to  the  mother,  and  still  more  to 
the  child,  increases  seriously  with  each  hour  that  elapses.  If  we  find 
the  progress  slow  and  unsatisfactory,  the  pains  flagging  and  insufficient, 
and  incapable  of  being  intensified  by  the  means  indicated,  then,  pro- 
vided the  head  be  low  in  the  pelvis,  it  is  better  to  assist  at  once  by  the 
forceps,  rather  than  to  wait  until  we  are  driven  to  do  so  by  the  state  of 
the  patient.^ 

'  Obfit.  Trans.,  vol.  xiii. 

^  It  may  perhaps  be  of  interest  in  connection  with  this  important  topic  in  practical 
midwifery  if  I  reprint  a  letter  I  published  some  years  ago  in  the  Bledical  Times  and 
Gazette.  An  historical  case,  such  as  that  of  which  it  treats,  will  better  illustrate  the 
evil  effects  that  may  follow  unnecessary  delay  than  any  amount  of  argument.  It  seems 
to  me  impossible  to  read  the  details  of  the  delivery  it  describes  without  being  forcibly 
struck  with  the  disastrous  results  which  followed  the  practice  adopted,  which,  however, 
was  strictly  in  accordance  with  that  which,  up  to  a  quite  recent  date,  has  been  consid- 
ered correct  by  the  highest  obstetric  authorities: 

ON  THE  DEATH  OF  THE  PEINCESS  CHARLOTTE  OF  WALES. 

[To  the  Editor  of  the  Medical  Times  aiul  Ga~etle.] 

Sir  :  The  letter  of  your  correspondent,  "An  Old  Accoucheur,"  regarding  the  death 
of  the  Princess  Charlotte,  raises  a  question  of  great  interest — viz.  whether  the  fatal 
result  might  have  been  averted  under  other  treatment.  The  history  of  the  case  is  most 
instructive,  and  I  think  a  careful  consideration  of  it  leaves  little  room  to  doulit  that, 
though  the  management  of  the  labor  was  quite  in  accordance  with  the  teaching  of  the 
day,  it  was  entirely  opposed  to  that  of  modern  obstetric  science.  The  following  account 
of  the  labor  may  interest  your  readers,  and  will  probably  be  new  to  most  of  them.  It  is 
contained  in  a  letter  from  Dr.  John  Sims  to  the  late  Dr.  Joseph  Clarke  of  Dublin : 

"  London,  November  15,  isi7. 
"My  Dear  Sir:  I  do  not  wonder  at  your  wishing  to  have  a  correct  statement  of 
the  labor  of  her  Royal  Highness  the  Princess  Charlotte,  the  fatal  issue  of  which  has 
involved  the  whole  nation  in  distress.  You  nuist  excuse  my  being  veiy  concise,  as  I 
have  been  and  am  very  much  hurried.  I  take  the  opportunity  of  writing  this  in  a 
lying-in  chamber.  Pier  Royal  Highness's  labor  commenced  by  the  discharge  ol'  the 
liquor  amnii  about  seven  o'clock  on  Monday  evening,  and  the  pains  followed  soon 
after.     They  continued  through  the  night  and  a  greater  part  of  the  next  day — sharp, 


PROLONGED  AND  PBECIPITATE  LABORS.  349 

Precipitate  Labor  less  Common  than  Lingering. — Undue  rapidity  of 
labor  is  certainly  more  uncommon  than  its  converse,  but  still  it  is  by  no 

soft,  but  very  ineifectual.  Toward  the  evening  Sir  Richard  Croft  began  to  suspect  that 
labor  might  not  terminate  without  artificial  assistance,  and  a  message  was  despatched 
for  me.  I  arrived  at  two  on  Wednesday  morning.  The  labor  was  now  advancing 
more  favorably,  and  both  Dr.  Baillie  and  myself  concurred  in  the  opinion  that  it  would 
not  be  advisable  to  inform  her  Royal  Highness  of  my  arrival.  From  this  time  to  the 
end  of  her  labor  the  progress  was  uniform,  though  very  slow,  the  patient  in  good 
spirits,  the  pulse  calm,  and  there  never  was  room  to  entertain  a  question  about  the 
use  of  instruments.  About  six  in  the  afternoon  the  discharge  became  of  a  green  color, 
which  led  to  a  suspicion  that  the  child  might  be  dead  ;  still,  the  giving  assistance  was 
quite  out  of  the  question,  as  the  pains  now  became  more  eflectual  and  the  labor  pro- 
ceeded regularly  though  slowly.  The  child  was  born  without  artificial  assistance  at 
nine  o'clock  in  the  evening.  Attempts  were  made  for  a  good  while  to  reanimate  it  by 
inflating  the  lungs,  friction,  hot  baths,  etc.,  but  without  efiect ;  the  heart  could  not  be 
made  to  beat  even  once.  Soon  after  delivery  Sir  Richard  Croft  discovered  that  the 
uterus  was  contracted  in  the  middle  in  the  hour-glass  form,  and  as  some  hemorrhage 
commenced,  it  was  agreed  that  the  placenta  should  be  brought  away  by  introducing 
the  hand.  This  was  done  about  half  an  hour  after  the  delivery  of  the  child,  with  more 
€ase  and  less  blood  than  usual.  Her  Royal  Highness  continued  well  for  about  two 
hours  ;  she  then  complained  of  being  sick  at  stomach  and  of  noise  in  the  ears,  began  to 
be  talkative,  and  her  pulse  became  frequent ;  but  I  understand  she  was  very  quiet  after 
this,  and  her  pulse  calm.  About  half-past  twelve  o'clock  she  complained  of  severe 
pain  in  the  chest,  became  extremely  restless,  with  rapid,  weak,  and  irregular  pulse. 
At  this  time  1  saw  her  for  the  first  time.  It  has  been  said  that  we  had  all  gone  to  bed, 
but  that  is  not  a  fact:  Croft  did  not  leave  her  room,  Baillie  retired  about  eleven,  and  I 
went  to  my  bed-chamber  and  laid  down  in  my  clothes  at  twelve.  By  dissection,  some 
bloody  fluid  (two  ounces)  was  found  in  the  pericardium,  supposed  to  be  thrown  out  in 
ariiculo  mortis.  The  brain  and  other  organs  all  sound,  except  the  right  ovarium,  which 
was  distended  into  a  cyst  the  size  of  a  hen's  egg.  The  hour-glass  contraction  of  the 
uterus  still  visible,  and  a  considerable  quantity  of  blood  in  the  cavity  of  the  uterus  — 
but  those  present  dispute  about  the  quantity,  so  much  as  from  twelve  ounces  to  a  pound 
and  a  half — her  uterus  extending  as  high  as  her  navel.  The  cause  of  her  Royal  High- 
ness's  death  is  certainly  somewhat  obscure ;  tlie  symptoms  were  such  as  attend  death 
from  hemorrhage,  but  the  loss  of  blood  did  not  seem  to  be  sufficient  to  account  for  a 
fatal  issue.  It  is  possible  that  the  effusion  into  the  pericardium  took  place  earlier  than 
was  supposed,  and  it  does  not  seem  to  be  quite  certain  that  this  might  not  be  the  cause. 
That  1  did  not  see  her  Royal  Highness  more  early  was  awkward,  and  it  would  have 
been  better  that  I  had  been  introduced  before  the  labor  was  expected ;  and  it  should 
have  been  understood  that  when  labor  came  on  I  should  be  sent  to  without  waiting  to 
know  whether  a  consultation  was  necessary  or  not.  I  thought  so  at  the  time,  but  I 
could  not  propose  such  an  arrangement  to  Croft.  But  this  is  entirely  entre  ?iow.s.  I  am 
glad  to  hear  that  your  son  is  well,  and,  with  all  my  family,  wish  to  be  remembered  to 
him.     We  were  happy  to  hear  that  he  was  agreeably  married. 

"  I  remain,  my  dear  doctor, 

"  Ever  yours,  most  truly, 

"  John  Sims,  M.  D. 

"  This  letter  is  confidential,  as  perhaps  I  might  be  blamed  for  writing  any  particulars 
without  the  permission  of  Prince  Leopold." 

What  are  the  facts  here  shown  ?  Here  was  a  delicate  young  woman  prepared  for 
the  trial  before  her,  as  Baron  Stockmar  tells  us,  by  "lowering  tlie  organic  strength  of 
the  mother  by  bleeding,  aperients,  and  low  diet,"  who  was  allowed  to  go  on  in  linger- 
ing, feeble  labor  foj-  no  less  tlum  fifty-two  hours  after  the  escape  of  the  liquor  amnii ! 
Suf!li  was  the  groundless  dread  of  instrumental  interference  then  ])revalent  tliat, 
although  the  case  dragged  on  its  weary  length  with  feeble,  inefi'ectual  pains,  every 
now  and  tlieu  increasing  a  little  in  intensity  and  then  falling  oft'  again,  it  is  stated 
''there  never  was  room  to  entertain  a  (question  about  the  use  of  instruments;"  and 
even  "  wlien  tlie  discluirge  became  of  a  green  color,  ....  still,  the  giving  assistance 
was  (piite  out  of  the  question"  !  (Jan  any  reasonable  man  doubt  tliat  if  the  forceps  had 
Iteen  employed  hours  and  hours  Ijefore — say  on  Tuesday,  when  the  pains  fell  oft^ — the 
result  would  j)robably  have  been  very  diflL'rent,  and  that  the  life  of  the  child,  destroyed 
by  the  enormously-prolonged  second  stage,  would  have  been  saved  ?  It  nuist  be  remem- 
bered that  early  on  Tuesdiiy  morning  delivery  was  expected,  so  that  tlie  head  must 


350  LABOR. 

means  of  iinfrequent  occurrence.  Most  obstetric  works  contain  a  for- 
midable catalo!j;ue  of  evils  that  may  attend  it,  such  as  rupture  of  the 
cervix,  or  even  of  the  uterus  itself,  from  the  violence  of  the  uterine 
action ;  laceration  of  the  perineum  from  the  presenting  part  being  driven 
through  before  dilatation  has  occurred ;  fainting  from  the  sudden  empty- 
ing of  the  uterus;  hemorrhage  from  the  same  cause.  With  regard  to  the 
child,  it  is  held  that  the  pressure  to  which  it  is  subjected,  and  sudden 
expulsion  while  the  mother  is  in  the  erect  position,  may  prove  injurious. 
Without  denying  that  these  results  may  possibly  occur  now  and  again, 
in  the  majority  of  cases  over-rapid  labor  is  not  attended  with  any  evil 
eifects. 

Precipitate  labor  may  generally  be  traced  to  one  of  two  conditions,  or 
to  a  combination  of  both  :  excessive  force  and  rapidity  of  the  pains  or 
unusual  laxity  and  want  of  resistance  of  the  soft  parts.  The  precise 
causes  inducing  these  it  is  difficult  to  estimate.  In  some  cases  the 
former  may  depend  on  an  undue  amount  of  nervous  excitability,  and 
the  latter  on  the  constitutional  state  of  the  patient,  tending  to  relaxation 
of  the  tissues. 

Whatever  the  cause,  the  extreme  rapidity  of  labor  is  occasionally 
remarkable,  and  one  strong  pain  may  be  sufficient  to  effect  the  expul- 
sion of  the  child  with  little  or  no  preliminary  warning.  I  have  known 
a  child  to  be  expelled  into  the  pan  of  a  water-closet,  the  only  previous 
indication  of  commencing  labor  being  a  slight  griping  pain,  v/hich  led 
the  mother  to  fancy  that  an  action  of  the  bowels  was  about  to  take  place. 
More  often  there  is  what  may  be  described  as  a  storm  of  uterine  contrac- 
tions, one  pain  following  the  other  with  great  intensity  until  the  foetus  is 
expelled.  The  natural  effect  of  this  is  to  produce  a  great  amount  of 
alarm  or  nervous  excitement,  which  of  itself  forms  one  of  the  worst 
results  of  this  class  of  labor.     It  is  under  such  circumstances  that  tem- 

then  have  been  low  in  the  pelvis  {vide  Stockmar's  Memoirs,  vol.  i.  p.  63).  It  would  be 
difficult  to  find  a  case  which  more  forcibly  illustrates  the  danger  of  delay  in  the  second 
.stage  of  labor.  Then  what  follows?  The  uterus,  exhausted  by  the  lengthy  efforts  it 
.should  have  been  spared,  fails  to  contract  effectually,  nor  do  we  hear  of  any  attempts  to 
produce  contraction  by  pressure.  The  relaxed  organ  becomes  full  of  clots,  extending 
up  to  the  umbilicus,  and  all  the  most  characteristic  symptoms  of  concealed  post-partum 
hemorrhage  develop  themselves.  She  complained  "  of  being  sick  at  stomach  and  of 
noise  in  her  eai's — began  to  be  talkative,  and  her  pulse  became  frequent."  Before  long 
other  symptoms  came  on,  graphically  described  by  Baron  Stockmar,  and  which  seem 
to  point  to  the  formation  of  a  clot  in  the  heart  and  pulmonary  arteries — a  most  likely 
occurrence  after  such  a  history.  "  Baillie  sent  me  word  that  he  wished  me  to  see  the 
princess.  I  hesitated,  but  at  last  went  with  him.  She  was  suffering  from  spasnis  of 
the  chest  and  difficulty  of  breathing,  in  great  pain,  and  very  restless,  and  threw  her- 
self continually  from  one  side  of  the  bed  to  the  other,  speaking  now  to  Baillie,  now  to 
(.'roft.  Bnillie  said  to  her,  '  Here  comes  an  old  friend  of  yours.'  She  held  out  her  left 
hand  to  me  hastily,  and  pressed  mine  warmly  twice.  I  felt  her  pulse ;  it  was  going 
very  fast — the  beats  now  strong,  now  feeble,  now  intermittent." 

Here  was  evidently  something  different  from  the  exhaustion  of  hemorrhage;  and  no 
one  who  has  witnessed  a  case  of  pulmonary  obstruction  can  fail  to  recognize  in  tliis 
account  an  accurate  delineation  of  its  dreadful  symptoms. 

Surely  this  lamentable  story  can  only  lead  to  the  conclusion  that  the  unhappy  and 
gifted  princess  fell  a  victim  to  the  dread  of  that  bugbear,  "  meddlesome  midwifery," 
which  has  so  long  retarded  the  progress  of  obstetrics. 

I  am,  etc., 

W.  S.  Playfaik. 

Curzon  Street,  Mayfair,  W.,  November  29,  1872. 


OBSTRUCTION  FROM  CONDITION   OF  SOFT  PARTS.  351 

poraiy  mania  occurs,  produced  by  the  intensity  of  the  suffering,  under 
which  the  patient  may  commit  acts,  her  responsibility  for  which  may 
fairly  be  open  to  question. 

Treatment. — Little  can  be  done  in  treating  undue  rapidity  of  labor. 
A¥e  can,  to  some  extent,  modify  the  intensity  of  the  pains  by  urging  the 
patient  to  refrain  from  voluntary  efforts  and  to  open  the  glottis  by  cry- 
ing out,  so  that  the  chest  may  no  longer  be  a  fixed  point  for  muscular 
action.  Opiates  have  been  advised  to  control  uterine  action,  but  it  is 
needless  to  point  out  that  in  most  cases  there  is  no  time  for  them  to  take 
effect.  Chloroform  will  often  be  found  most  valuable,  from  the  rapidity 
with  which  it  can  be  exhibited  ;  and  its  power  of  diminishing  uterine 
action,  Avhich  forms  one  of  its  chief  drawbacks  in  ordinary  practice,  will 
here  prove  of  much  service. 


CHAPTER  X. 

LABOE  OBSTEUCTED  BY  FAULTY  CONDITION  OF  THE  SOFT  PAETS. 

Rigidity  of  the  Cervix  a  Frequent  Cause  of  Protracted  Labor. — One 
of  the  most  frequent  causes  of  delay  in  the  first  stage  of  labor  is  rigidity 
of  the  cervix  uteri,  which  may  depend  on  a  variety  of  conditions.  It  is 
often  produced  by  premature  escape  of  the  liquor  amnii,  in  consequence 
of  which  the  fluid  wedge  which  is  nature's  means  of  dilating  the  os  is 
destroyed,  and  the  hard  presenting  part  is  consequently  brought  to  bear 
directly  upon  the  tissues  of  the  cervix,  which  are  thus  unduly  irritated 
and  thrown  into  a  state  of  spasmodic  contraction.  At  other  times  it 
may  be  due  to  constitutional  peculiarities,  among  which  there  is  none  so 
common  as  a  highly  nervous  and  emotional  temperament,  which  renders 
the  patient  peculiarly  sensitive  to  her  sufferings  and  interferes  with  the 
harmonious  action  of  the  uterine  fibres.  The  pains  in  such  cases  cause 
intense  agony,  are  short  and  cramp-like  in  character,  but  have  little  or 
no  effect  in  producing  dilatation,  the  os  often  remaining  for  many  hours 
without  any  appreciable  alteration,  its  edges  being  thin  and  tightly 
stretched  over  the  head.  Less  often — and  this  is  generally  met  with  in 
stout,  plethoric  women — the- edges  of  the  os  are  thick  and  tough. 

Effects. — The  effects  of  prolongation  of  labor  from  this  cause  will 
vary  much  under  different  circumstances.  If  the  liquor  amnii  be  pre- 
maturely evacuated,  the  presenting  part  presses  directly  upon  the  cervix, 
and  the  case  is  then  practically  the  same  as  if  the  labor  were  in  the 
second  stage.  Hence,  grave  symptoms  may  soon  develop  themselves, 
and  early  interference  may  l)c  im])eratively  demanded.  If  the  mem- 
branes be  unruptured,  delay  will  be  of  comparatively  little  moment,  and 
considerable  time  may  elapse  without  serious  detriment  to  either  the 
mother  or  child. 

Treatment. — The  treatniMit  will   naturally  vary  nuich  with  the  cause 


352  LAB  OB. 

and  the  state  of  the  patient.  In  the  majority  of  cases,  especially  if  the 
membranes  be  still  intact,  patience  and  time  are  sufficient  to  overcome 
the  obstacle  -^  but  it  is  often  in  the  power  of  the  accoucheur  materially  to 
aid  dilatation  by  appropriate  management.  Sometimes  nature  overcomes 
the  obstruction  by  lacerating  the  opposing  structures,  and  cases  are  on 
record  in  which  even  a  complete  ring  of  the  cervix  has  been  torn  oif  and 
come  away  before  the  head. 

IMany  remedies  have  been  recommended  for  facilitating  dilatation, 
some  of  which  no  doubt  act  beneficially.  Among  those  most  frequently 
resorted  to  was  venesection,  and  with  it  was  generally  associated  the 
administration  of  nauseating  doses  of  tartar  emetic.  Both  of  these  acted 
by  producing  temporary  depression,  under  which  the  resistance  of  the 
soft  part  was  lessened.  They  probably  answer  best  in  cases  in  which 
there  was  a  rigid  and  tough  cervix ;  and  they  might  prove  serviceable 
even  yet  in  stout,  plethoric  women  of  robust  frame.  Practically,  they 
are  now  seldom  if  ever  employed,  and  other  and  less  debilitating  reme- 
dies are  preferred.  The  agent,  par  excellence,  which  is  most  serviceable 
is  chloral,  which  is  of  special  value  in  the  more  common  cases  in  which 
rigidity  is  associated  with  spasmodic  contraction  of  the  muscular  fibres 
of  the  cervix.  Two  or  three  doses  of  15  grains,  repeated  at  intervals 
of  twenty  minutes,  are  often  of  almost  magical  efficacy,  the  pains  becom- 
ing steady  and  regular  and  the  os  gradually  relaxing  sufficiently  to  allow 
the  passage  of  the  head.  Should  the  chloral  be  rejected  by  the  stomach, 
it  may  be  satisfactorily  administered  per  rectum.  Chloroform  acts  much 
in  the  same  way,  but  on  the  whol,e  less  satisfactorily,  its  effects  being 
often  too  great ;  while  the  peculiai'value  of  chloral  is  its  influence  in 
promoting  relaxation  of  the  tissues  without  interfering  with  the  strength 
of  the  pains. 

Local  Means  of  Treatment. — Various  local  means  of  treatment  may 
be  also  advantageously  used.  One  is  the  warm  bath,  which  is  much 
used  in  France.  It  is  of  unquestionable  value  wdiere  there  is  mere 
rigidity,  and  may  be  used  either  as  an  entire  bath  or  as  a  hip-bath,  in 
which  the  patient  sits  from  twenty  minutes  to  half  an  hour.  The  objec- 
tion is  the  fuss  and  excitement  it  causes,  and  for  this  reason  it  is  an 
expedient  seldom  resorted  to  in  this  country.  A  similar  effect  is  pro- 
duced, and  much  more  easily,  by  a  douche  of  tepid  water  upon  the  cer- 
'  vix.  This  can  be  very  easily  administered,  the  pipe  of  a  Higginson's 
syringe  being  guided  up  to  the  cervix  by  the  index  finger  of  the  right 
hand,  and  a  stream  of  water  projected  against  it  for  five  or  ten  minutes. 
Smearing  the  os  with  extract  of  belladonna  is  advised  by  continental 
authorities,  but  its  effects  are  more  than  doubtful.  Horton^  advocates 
the  injection  into  the  tissue  of  the  cervix  of  ^  of  a  grain  of  atropine 
by  means  of  a  hypodermic  syringe,  and  speaks  very  favorably  of  tlie 
practice. 

Artificial  Dilatation. — Artificial  dilatation  of  the  cervix  by  the  finger 
has  often  been  recommended,  and  has  been  the  subject  of  much  discus- 
sion, especially  in  the  Edinburgh  school,  where  it  Mas  formerly  commonly 
employed.  It  is  capable  of  being  very  useful,  but  it  may  also  do  much 
injury  when  roughly  and  injudiciously  used.    The  class  of  cases  in  which 

^  Amer.  Joimi.  of  ObsL,  July,  1878. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  353 

it  is  most  serviceable  are  those  in  which  the  liquor  amnii  has  been  long 
evacuated,  and  in  which  the  head,  covered  by  the  tightly-stretched  cer- 
vix, has  descended  low  into  the  pelvic  cavity.  Under  these  circum- 
stances, if  the  finger  be  passed  gently  within  the  os  during  a  pain,  and 
its  margin  pressed  upward  and  over  the  head,  as  it  were,  while  the  con- 
traction lasts,  the  progress  of  the  case  may  be  materially  facilitated. 
This  manoeuvre  is  somewhat  similar  to  that  which  has  been  already 
spoken  of  when  the  anterior  lip  of  the  cervix  is  caught  between  the  head 
and  the  pubic  bone,  and  if  properly  performed  I  believe  it  to  be  quite 
safe  and  often  of  great  value.  It  is  not,  however,  well  adapted  for  those 
cases  in  which  the  membranes  are  still  intact,  or  in  which  the  os  remains 
undilated  when  the  head  is  still  high  in  the  pelvis.  When  there  is  much 
delay  under  these  conditions,  and  interference  of  some  kind  seems  called 
for,  the  dilatation  may  be  much  assisted  by  the  use  of  caoutchouc  dila- 
tors, described  in  the  chapter  on  the  induction  of  premature  labor,  which 
imitate  nature's  method  of  opening  up  the  os,  and  also  act  as  a  direct 
stimulant  to  uterine  contraction.  But  it  should  be  remembered  that  it 
is  precisely  in  such  cases  that  delay  is  least  prejudicial.  If,  however, 
the  OS  be  excessively  long  in  opening,  its  dilatation  may  be  safely  and 
efficiently  promoted  by  passing  within  it,  and  distending  with  water, 
one  of  the  smallest-sized  bags ;  and  after  this  has  been  in  position 
from  ten  to  twenty  minutes  it  may  be  renioved  and  a  larger  one 
substituted. 

Rigidity  depending  upon  Organic  Causes. — Every  now  and  again 
we  meet  with  cases  in  which  the  obstacle  depends  upon  organic  changes 
in  the  cervix,  the  most  common  of  which  are  cicatricial  hardening  from 
former  lacerations,  hypertrophic  elongation  of  the  cervix  from  disease 
antecedent  to  pregnancy,  or  even  agglutination  and  closure  of  the  os 
uteri.  Cicatrices  are  generally  the  result  of  lacerations  during  former 
labors.  They  implicate  a  portion  only  of  the  cervix,  which  they  render 
hard,  rigid,  and  undilatable,  while  the  remainder  has  its  natural  soft- 
ness. They  can  readily  be  made  out  by  the  examining  finger.  A  some- 
what similar  but  much  more  formidable  obstruction  is  occasionally  met 
with  in  cases  of  old-standing  hypertrophic  elongation  of  the  cervix, 
which  is  generally  associated  with  prolapse.  In  most  cases  of  this  kind 
the  cervix  becomes  softened  during  pregnancy,  so  that  dilatation  occurs 
without  any  unusual  difficulty.  But  this  does  not  always  happen.  A 
good  example  is  related  by  Mr.  Roper  in  the  seventh  volume  of  the 
Obstetrical  Transactions,  in  which  such  a  cervix  formed  an  almost  insu- 
perable obstacle  to  the  passage  of  the  child. 

Carcinoma  of  the  cervix  uteri,  which  produces  extensive  thickening 
and  induration  of  its  tissues,  and  even  advanced  malignant  disease  of  the 
uterus,  is  no  bar  to  conception.  The  relations  of  malignant  disease  to 
pregnancy  and  parturition  have  recently  been  well  studied  by  Dr.  Her- 
man.^ He  concludes  that  cancer  renders  the  patient  inapt  to  conceive, 
but  that  wlien  pregnancy  docs  occur  there  is  a  tendency  to  the  intra- 
uterine death  and  premature  expulsion  of  the  foetus,  and  the  growth  of 
the  cancer  is  accelerated.  When  delivery  is  accomplished  naturally, 
there  is  generally  expansion  of  the  cervix  by  Assuring  of  its  tissue, 

'  Obxt.  Trans.,  vol.  xx.  p.  191. 
23 


354  LABOR. 

but  the  harder  forms  of  cancer  may  form  an  insuperable  obstacle  to 
delivery. 

Occludon  of  the  Os. — Agglutination  of  the  margins  of  the  os  uteri  is 
occasionally  met  with,  and  must,  of  course,  have  occurred  after  concep- 
.tion.  It  is  generally  the  result  of  some  inflammatory  affection  of  the 
cervix  during  the  early  months  of  gestation  ;  and  I  have  known  it  to  recur 
in  the  same  woman  in  two  successive  pregnancies.  Usually  it  is  not 
associated  with  any  hardness  or  rigidity,  but  the  entire  cervix  is 
stretched  over  the  presenting  part,  and  forms  a  smooth  covering,  in 
which  the  os  may  only  exist  as  a  small  dimple  and  may  be  very  difficult 
to  detect  at  all.  Occlusion  of  the  os  uteri  from  inflammatory  change 
sometimes  so  alters  the  cervix  that  no  sign  of  the  original  opening 
can  be  discovered ;  and  in  two  such  instances  the  Ceesarean  operation 
has  been  j)erformed  in  the  United  States,  by  which  the  women  were 
saved.  ^ 

Treatment. — Any  of  these  mechanical  causes  of  rigidity  may  at  first  be 
treated  in  the  same  way  as  tb*e  more  simple  cases ;  and  with  patience, 
the  use  of  chloral  and  chloroform,  and  of  the  fluid  dilators,  sufficient 
expansion  to  permit  the  passage  of  the  head  will  often  take  place.  But 
if  these  methods  produce  no  effect,  and  symptoms  of  constitutional  irri- 
tation are  beginning  to  develop  themselves,  other  and  more  radical  means 
of  overcoming  the  obstruction  may  be  required. 

Incision  of  the  Cervix. — Under  such  circumstances  incision  of  the  cer- 
vix may  be  not  only  justifiable,  but  essential,  and  it  frequently  answers 
extremely  well.  On  the  Continent  it  is  resorted  to  much  more  fre- 
quently and  earlier  than  in  this  country,  and  with  the  most  beneficial 
results.  The  operation  offers  no  difficulties.  The  simplest  way  of  per- 
forming it  is  to  guard  the  greater  portion  of  the  blade  of  a  straight, 
blunt-pointed  bistoury  by  wrapping  lint  or  adhesive  plaster  round  it, 
leaving  about  half  an  inch  cutting  edge  toward  its  point.  This  is 
guided  to  the  cervix  on  the  under  surface  of  the  index  finger,  and  three 
or  four  notches  are  cut  in  the  circumference  of  the  os  to  about  the  depth 
of  a  quarter  of  an  inch.  Very  generally,  especially  when  the  obstruc- 
tion is  only  due  to  old  cicatrices,  the  pains  will  now  speedily  effect  com- 
plete expansion,  which  may  be  very  advantageously  aided  by  applying 
the  hydrostatic  dilators.  When  the  obstruction  is  due  to  carcinomatous 
infiltration  or  inflammatory  thickening,  the  case  is  much  more  compli- 
cated, and  will  painfully  tax  the  resources  of  the  accoucheur.  If  it  is 
possible,  the  disease  should  be  removed  as  much  as  can  be  safely  done 
during  pregnancy,  which  should  also  be  brought  to  an  end  before  the 
full  period.  During  labor,  incisions  should  form  a  preliminary  to  any 
subsequent  proceedings  that  may  be  necessary,  as  they  are,  at  the  worst, 
not  likely  to  increase  in  the  least  the  risk  the  patient  has  to  run,  and 
they  may  possibly  avert  more  serious  operations.  In  the  case  of  malig- 
nant disease  the  risk  of  serious  hemorrhage,  from  the  great  vascularity 
of  the  tissues,  must  not  be  forgotten,  and,  if  necessary,  means  must  be 
taken  to  check  this  by  local  styptics,  such  as  perchloride  of  iron.  If 
incision  fail  and  the  state  of  the  patient  demands  speedy  delivery,  the 
forceps  may  be  applied ;  and  Herman  thinks  they  are,  as  a  rule,  better 

^  Harris's  note  to  second  American  edition. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  355 

than  turning.  He  also  maintains  that  there  is  little  difference  in  the 
risk  to  the  mothers  between  craniotomy  and  the  Csesarean  section,  and 
that  the  possibility  of  saving  the  child  in  cases  in  which  incisions  have 
failed  should  induce  us  to  prefer  the  latter. 

Application  of  the  Forceps  within  the  Cervix. — Before  performing 
craniotomy,  when  the  os  is  sufficiently  open,  a  cautious  application  of 
the  forceps  is  quite  justifiable.  Steady  and  careful  downward  traction, 
combined  with  digital  expansion,  has  often  enabled  a  head  to  pass  with 
'safety  through  an  os  that  has  resisted  all  other  means  of  dilatation,  and 
the  destruction  of  the  child  has  thus  been  avoided.  If,  indeed,  the  os 
appear  to  be  dilatable,  this  procedure  may  advantageously  be  adopted 
before  incision,  and,  as  a  matter  of  fact,  it  is  commonly  practised  in  the 
Rotunda  Hospital.  An  operation  involving,  beyond  doubt,  of  itself 
some  risk,  and  requiring  considerable  operative  dexterity,  should  natu- 
rally not  be  lightly  and  inconsiderately  undertaken.  But  when  it  is 
remembered  that  the  alternative  is  the  destruction  of  the  child,  the  risk 
of  exhaustion,  and  at  least  as  great  mechanical  injury  to  the  mother,  its 
difficulty  need  not  stand  in  the  way  of  its  adoption. 

Treatment  ivhen  Occlusion  of  the  Os  Exists. — When  the  os  is  appa- 
rently obliterated,  incision  is  the  only  resource.  Before  resorting  to  it 
the  patient  should  be  placed  under  chloroform  and  the  entire  lower  seg- 
ment of  the  uterus  carefully  explored.  Possibly,  the  aperture  may  be 
found  high  up  and  out  of  readi  of  an  ordinary  examination,  or  we  may 
detect  a  depression  corresponding  to  its  site.  A  small  crucial  incision 
may  then  be  made  at  the  site  of  the  os,  if  this  can  be  ascertained  ;  if  not, 
at  the  most  prominent  portion  of  the  cervix.  Very  generally,  the  pains 
will  then  suffice  to  complete  expansion,  which  may  be  further  aided  by 
the  fluid  dilators. 

Ante-partum  Hour-glass  Contraction. — Dr.  Hosmer^  has  recently 
drawn  attention  to  a  hitherto  undescribed  species  of  dystocia,  which  he 
terms  "  ante-partum  hour-glass  contraction,'^  and  which  he  believes  to 
depend  on  constriction  of  the  uterine  fibres  at  the  site  of  the  internal  os 
uteri.  Harris^  doubts  its  limitation  to  the  internal  os  uteri,  and  terms 
it  " tetanoid  falciform  constriction  of  the  uterus.^'  Whatever  its  site,  in 
the  cases  recorded  difficulties  of  the  most  formidable  kind  arose  from 
this  cause.  The  pelves  were  normal  and  the  presentations  natural,  yet 
out  of  7  labors  4  ended  fatally,  2  before  delivery.  P]  The  constriction 
seems  to  have  grasped  the  foetus  with  such  force  as  to  have  rendered 
extraction  either  by  the  forceps  or  turning  impossible.  I  have  no  per- 
sonal experience  of  this  complication,  which  must  fortunately  be  very 
rare.  Tlie  introduction  of  the  hand,  the  patient  being  deeply  ansestlie- 
tize.'l,  would  probal^ly  render  diagnosis  easy.  The  treatment  must 
depend  on  the  force  and  amount  of  constriction.  If  the  constriction 
does  not  relax  under  chloroform,  chloral,  or  the  injection  of  atropine 
into  the  site  of  constriction,  as  recommended  by  Horton  in  rigidity  of 
the  cervix,  turning  would  probably  be  our  best  resource.  Should  this 
fail,  the  Cesarean  section  maybe  required  to  effect  delivery,  as  happened 

'  BoHtnn  Med.  and  Sim;.  Jovrv.,  March  and  May,  1878. 
''  Iliirris's  note  to  second  American  edition. 
P  Of  'M  labors,  0  ended  fatally  ;  20  children  were  lost.  — Ed.] 


356  LABOR. 

in  a  case  recorded  by  Dr.  T.  A.  Foster  of  Portland,  Maine.  Gastro- 
elytrotomy  is  obviously  unsuitable  for  such  cases. 

Bands  and  Cicatrices  in  the  Vagina. — Extreme  rigidity  of  the  vagina, 
or  bands  and  cicatrices  in  or  across  its  walls,  the  result  of  congenital 
malformation,  of  injuries  in  former  labors,  or  of  antecedent  disease,  occa- 
sionally obstruct  the  second  stage.  There  is  seldom  any  really  formid- 
able difficulty  from  this  cause,  since  the  obstruction  almost  ahvays  yields 
to  the  pressure  of  the  presenting  part.  If  there  be  any  considerable 
extent  of  cicatrices  in  the  vagina,  artificial  assistance  may  be  required. 
If  we  should  be  aware  of  their  existence  during  pregnancy,  and  find 
them  to  be  sufficiently  dense  and  extensive  to  be  likely  to  interfere  with 
delivery,  an  endeavor  may  be  made  to  dilate  them  gradually  by  hydro- 
static bags  or  bougies.  If  they  be  not  detected  until  labor  is  in  prog- 
ress, we  must  be  guided  in  our  procedure  by  the  pressure  to  which  they 
are  subjected.  It  may  then  be  necessary  to  divide  them  with  a  knife 
and  to  hasten  the  passage  of  the  head  by  the  forceps,  so  as  to  prevent 
contusion  as  much  as  possible.  It  is  obviously  impossible  to  lay  down 
any  positive  rules  for  such  rare  contingencies,  the  treatment  suitable  for 
A\hich  must  necessarily  vary  much  with  the  individual  peculiarities  of 
the  case. 

Extreme  rigidity  of  the  perineum  is  often  dependent  upon  cicatricial 
hardening  from  injury  in  previous  labors.  This  may  greatly  interfere 
with  its  dilatation ;  and  if  laceration  seems  inevitable,  we  may  be  quite 
justified  in  attempting  to  avert  it  by  incision  of  the  margins  of  the  per- 
ineum, on  the  principle  of  a  clean  cut  being  always  preferable  to  a 
jagged  tear. 

Labor  Complicated  with  Tumor. — Occasionally  we  meet  with  very 
formidable  obstacles  from  tumors  connected  with  the  maternal  struc- 
tures. These  are  most  commonly  either  fibroid  or  ovarian,  although 
others  may  be  met  with,  such  as  malignant  growths  from  the  pelvic 
bones,  exostoses,  etc. 

Fibroid  Tumors  of  the  Uterus. — Considering  the  frequency  with  which 
women  suffer  from  fibroid  tumors  of  the  uterus,  it  is  perhaps  somewhat 
remarkable  that  they  do  not  more  often  complicate  delivery.  Probably 
women  so  affected  are  not  apt  to  conceive.  Occasionally,  however,  cases 
of  this  kind  cause  much  anxiety.  Of  course,  the  cases  are  most  grave 
in  which  tumors  are  so  situated  as  to  encroach  upon  the  cavity  of  the 
pelvis  and  mechanically  obstruct  the  passage  of  the  child.  Even  those 
in  which  this  does  not  occur  are  by  no  means  free  from  danger,  for  inter- 
stitial and  subperitoneal  fibroids,  situated  in  the  upper  parts  of  the  ute- 
rus and  leaving  the  pelvic  cavity  quite  unimplicated,  may  interfere  with 
the  action  of  the  uterine  fibres,  prevent  subsequent  contraction,  cause 
profuse  post-partum  hemorrhage,  or  even  predispose  to  rupture  of  the 
uterine  tissue.  Hence,  every  case  in  Avhich  the  existence  of  uterine 
fibroids  has  been  ascertained  must  be  anxiously  watched.  The  risk  of 
hemorrhage  is  perhaps  the  greatest,  for  if  the  tumors  be  at  all  large,  effi- 
cient contraction  of  the  uterus  after  the  birth  of  the  child  must  be  more 
or  less  interfered  with.  Fortunately,  it  is  not  so  common  as  might 
almost  be  expected.  Out  of  5  cases  recorded  in  the  Obstetrical  Transac- 
tions, 2  of  which  were  in  my  own  practice,  no  hemorrhage  occurred  ;  nor 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  357 

does  it  seem  to  have  happened  in  any  of  the  26  cases  collected  by  Mag- 
delaine  in  his  thesis  on  the  subject.  I  recently  saw  an  interesting  exam- 
ple of  this  in  a  patient  whose  case  was  looked  forward  to  with  much 
anxiety  in  consequence  of  the  existence  of  several  enormous  fibroid 
masses  projecting  from  the  fundus  and  anterior  surface  of  the  body  of 
the  uterus,  and  whose  labor  was,  nevertheless,  typically  normal  in  every 
way.  Should  hemorrhage  occur  after  delivery,  the  injection  of  styptic 
solutions  would  probably  be  peculiarly  valuable,  since  the  ordinary 
means  of  promoting  contraction  are  likely  to  fail. 

It  is  when  the  fibroid  growths  implicate  the  lower  uterine  zone  and 
the  cervical  region  that  the  greatest  difficulties  are  likely  to  be  met  with. 
The  practice  then  to  be  adopted  must  be  regulated  to  a  great  extent  by 
the  nature  of  each  individual  case.  If  it  be  possible  to  push  the  tumor 
ab,ove„the  pelvic  brim,  out  of  the  way  of  the  presenting  part,  that,  no 
doubt,  is  the  best  course  to  pursue,  as  not  only  clearing  the  passage  in 
the  most  effectual  way,  but  removing  the  tumor  from  the  bruising  to 
which  it  would  otherwise  be  subjected  when  pressed  between  the  head 
and  the  pelvic  walls ;  which  seems  to  be  one  of  the  greatest  dangers  of 
this  complication.  This  manoeuvre  is  sometimes  possible  in  what  seem 
to  be  the  most  unpromising  circumstances,  ^n  interesting  example  is 
narrated  by  Spencer  Wells,^  who,  called  to  perform  the  Csesarean  section, 
succeeded,  although  not  without  much  difficulty,  in  pushing  the  obstruct- 
ing mass  above  the  brim,  the  child  subsequently  passing  with  ease.  I 
have  myself  elsewhere  recorded  two  similar  cases  ^  in  which  I  was  en- 
abled to  deliver  the  patient  by  pushing  up  the  obstructing  tumor,  in  both 
of  which  the  Csesarean  section  would  have  been  inevitable  had  the 
attempt  at  reposition  failed.  Therefore,  before  resorting  to  more  seri- 
ous operative  procedures  a  determined  effort  at  pushing  the  tumor  out 
of  the  way  should  be  made,  the  patient  being  deeply  chloroformed,  and, 
if  necessary,  upward  pressure  being  made  by  the  closed  fist  passed  into 
the  vagina. 

Enucleation  or  Ablation. — Failing  this,  the  possibility  of  enucleating 
the  tumor,  or,  if  that  be  not  possible,  of  removing  it  piecemeal  with  the 
6craseur,  should  be  considered.  On  account  of  the  loos«  attachments  of 
these  growths,  and  the  facility  with  which  they  can  be  removed  in  this 
way  in  the  non-pregnant  state,  the  expedient  seems  certainly  well  worthy 
of  a  trial  if  their  site  and  attachments  render  it  at  all  feasible.  Inter- 
esting examples  of  the  successful  performance  of  this  operation  are 
recorded  by  Danyau  and  Braxton  Hicks.  Should  it  be  found  imprac- 
ticaljle,  the  case  must  be  managed  in  reference  to  the  amount  of  obstruc- 
tion, and  the  forceps,  craniotomy,  or  even  the  Csesarean  section,  may  be 
nec;essary. 

[The  records  of  Csesarean  delivery  show  a  great  mortality  in  cases 
where  the  dystocia  is  due  to  an  obstruction  produced  by  fibroid  tumors. 
In  Dr.  Sanger's  colkiction,''  excluding  tlie  Porro  operations,  we  find  39 
CVcsarean  sections,  with  31  deaths  :  8  of  the  39  are  credited  to  the  United 
States,  with  3  recoveries.  To  this  I  add  1  more  recovery  and  2  more 
deaths,  giving  us  4  saved  out  of  11,  or  42  cases  in  all,  with  9  women 

'  Obft.  Trann.,  vol.  ix.  p.  7.3.  ^  Ibirl.,  vol.  xix.  p.  101. 

[I* I)cr  KalaerHchnUl  hd  UleruKjibromen,  Leipzig,  1882,  pp.  12-23. — Ed.] 


358 


LABOR. 


saved.     An  early  resort  to  the  knife  and  suturing  the  uterine  wound 
promise  better  resuks  in  the  future. — Ed.] 

T'umo7's  of  the  Ovaries. — The  next  most  common  class  of  obstructing 
tumors  are  those  of  the  ovary  (Fig.  124) ;  and  it  is  apparently  not  the 
largest  of  these  which  are  most  apt  to  descend  into  the  pelvic  cavity. 
When  the  tumor  is  of  any  considerable  size,  its  bulk  is  such  that  it  can- 
not be  contained  in  the  true  pelvis,  and  it  rises  into  the  abdominal  cavity 

Fig.  124. 


Labor  complicated  by  Ovarian  Tumor. 


Math  the  uterus.  Hence,  the  existence  of  the  tumor  that  offers  the  most 
formidable  obstacle  to  the  delivery  is  rarely  suspected  before  labor  sets  in. 
In  order  to  estimate  the  results  of  the  various  methods  of  treatment, 
I  have  tabulated  57  cases.^  In  13  labor  was  terminated  by  the  natural 
powers  alone,  but  of  these  6  mothers,  or  nearly  one-half,  died.  In  fav- 
orable contrast  with  these  we  have  the  cases  in  which  the  size  of  the 
tumor  was  diminished  by  puncture.  These  are  9  in  number,  in  all  of 
which  the  mother  recovered,  5  out  of  the  6  children  being  saved.  The 
reason  of  the  great  mortality  in  the  former  cases  is  apparently  the  bruis- 
ing to  which  the  tumor,  even  when  small  enough  to  allow  the  child  to  be 
squeezed  past  it,  is  necessarily  subjected.  This  is  extremely  apt  to  set 
up  a  fatal  form  of  diffuse  inflammation,  the  risk  of  which  was  long  ago 
pointed  out  by  Ashwell,^  who  draws  a  comparison  between  cases  in  which 
such  tumors  have  been  subjected  to  contusion  and  cases  of  strangulated 
hernia ;  and  the  cause  of  death  in  both  is  doubtless  very  similar.  This 
danger  is  avoided  when  the  tumor  is  punctured,  so  as  to  become  flattened 
between  the  head  and  the  pelvic  walls.  On  this  account  I  think  it 
should  be  laid  down  as  a  rule  that  puncture  should  be  performed  in  all 
cases  of  ovarian  tumor  engaged  in  front  of  the  presenting  part,  even 
when  it  is  of  so  small  a  size  as  not  to  preclude  the  possibility  of  delivery 
by  the  natural  powers. 

'  Obst.  Trans.,  vol.  ix.  ^  Guy's  Hospital  Reports,  vol.  ii. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  359 

Treatment  when  Puncture  Fails. — In  5  of  the  57  cases  it  was  found 
possible  to  return  the  tumor  above  the  pelvic  brim,  and  in  these  also  the 
termination  was  very  favorable,  all  the  mothers  recovering.  Should 
puncture  not  succeed — and  it  may  fail  on  account  of  the  gelatinous  and 
semi-solid  nature  of  the  contents  of  the  cyst — it  may  be  possible  to  dis- 
pose of  the  tumor  in  this  way,  even  when  it  seems  to  be  firmly  wedged 
down  in  front  of  the  presenting  part  and  to  be  hopelessly  fixed  in  its 
unfavorable  position. 

Failing  either  of  these  resources,  it  may  be  necessary  to  resort  to 
craniotomy,  provided  the  size  of  the  tumor  precludes  the  possibility  of 
delivery  by  forceps. 

The  question  of  the  effect  on  labor  of  ovarian  tumor  which  does  not 
obstruct  the  pelvic  canal  is  one  of  some  interest,  but  there  are  not  a  suf- 
ficient number  of  cases  recorded  to  throw  much  light  on  it.  I  am  dis- 
posed to  think  that  labor  generally  goes  on  favorably.  What  delay 
there  is  depends  on  the  inefficient  action  of  the  accessory  muscles 
engaged  in  parturition,  on  account  of  the  extreme  distension  of  the 
abdomen. 

There  are  a  few  other  conditions  connected  with  the  maternal  struc- 
tures which  may  impede  delivery,  but  which  are  of  comparatively  rare 
occurrence. 

Vaginal  Cystocele. — Amongst  them  is  vaginal  cystocele,  consisting  of 
a  prolapse  of  the  distended  bladder  in  front  of  the  presentation,  where 
it  forms  a  tense  fluctuating  pouch,  which  has  been  mistaken  for  a  hydro- 
cephalic head  or  for  the  bag  of  membranes.  This  complication  is  only 
likely  to  arise  when  the  bladder  has  been  allowed  to  become  unduly  dis- 
tended from  want  of  attention  to  the  voiding  of  urine  during  labor. 
The  diagnosis  should  not  oifer  any  difficulty,  for  the  finger  will  be  able 
to  pass  behind,  but  not  in  front  of,  the  swelling,  and  reach  the  presenting 
part,  while  the  pain  and  tenesmus  will  further  put  the  practitioner  on 
his  guard.  The  treatment  consists  in  emptying  the  bladder ;  but  there 
may  be  some  difficulty  in  passing  the  catheter,  in  consequence  of  the 
urethra  being  dragged  out  of  its  natural  direction.  A  long  elastic  male 
catheter  will  almost  always  pass  if  used  with  care  and  gentleness.  Should 
it  be  found  impossible  to  draw  off  the  water — and  this  is  said  to  have 
sometimes  happened — ^the  tense  pouch  might  be  punctured  without  dan- 
ger by  the  fine  needle  of  an  aspirator-trocar  and  its  contents  withdrawn. 
When  once  the  viscus  is  emptied  it  can  easily  be  pushed  above  the  pre- 
senting part  in  the  intervals  between  the  pains. 

Vemcal  Calculus. — In  some  few  cases  difficulties  have  arisen  from  the 
existence  of  a  vesical  calculus.  Should  this  be  pushed  down  in  front 
of  the  head,  it  can  readily  be  understood  that  the  maternal  structures 
would  run  the  risk  of  being  seriously  bruised  and  injured.  Should  we 
make  out  the  existence  of  a  calculus — and  if  the  presence  of  one  be  sus- 
pected the  diagnosis  could  easily  be  made  by  means  of  a  sound — an 
endeavor  should  be  made  to  push  it  above  the  brim  of  the  pelvis.  If 
that  b(!  found  to  Imj  impossible;,  no  resource;  is  left  but  its  removal,  either 
])y  crusliing  or  by  rapid  dilatation  of  the  urethra,  followed  by  extrac- 
tion. Should  w(;  })(.'  awai'c  of  the  (ixistcuci;  of  a  calculus  during  i)reg- 
nancy,  its  removal  should  certainly  be  undertaken  before  labor  sets  in. 


360  LABOR. 

Hernial  protrusion  in  Douglas's  space  may  sometimes  give  rise  to 
anxiety,  from  the  pressure  and  contusion  to  which  it  is  necessarily  sub- 
jected. An  endeavor  must  be  made  to  replace  it  and  to  moderate  the 
straining  efforts  of  the  patient ;  and  it  may  even  be  advisable  to  a])ply 
the  forceps,  so  as  to  relieve  the  mass  from  pressure  as  soon  as  possible. 
It  is,  however,  of  great  rarity.  Fordyce  Barker  in  an  interesting  paper 
on  the  subject  ^  records  several  examjiles,  and  states  that  he  has  met  witli 
no  instance  in  which  it  has  led  to  a  fatal  result,  either  to  mother  or 
child,  although  it  cannot  but  be  considered  a  serious  complication. 

Scybalous  masses  in  the  intestines  may  be  so  hard  and  impacted  as  to 
form  an  obstruction.  The  necessity  of  attending  to  the  state  of  the  rec- 
tum has  already  been  pointed  out.  Should  it  be  found  impossible  to 
empty  the  bowel  by  large  enemata,  the  mass  must  be  mechanically  broken 
down  and  removed  by  the  scoop. 

GEdema  of  the  Vulva. — Excessive  cedematous  infiltration  of  the  vulva 
may  sometimes  cause  obstruction  and  require  diminution  in  size,  which 
can  easily  be  effected  by  numerous  small  punctures. 

Hcematic  effusions  into  the  cellular  tissue  of  the  vulva  or  vagina  form  a 
grave  complication  of  labor.  Such  blood-swellings  are  most  usually  met 
with  in  one  or  both  labia  or  under  the  vaginal  wall ;  in  the  gravest 
forms  the  blood  may  -extend  into  the  tissues  for  a  considerable  distance, 
as  in  the  case  recorded  by  Cazeaux,  where  it  reached  upward  as  far  as 
the  umbilicus  in  front  and  as  far  as  the  attachment  of  the  diaphragm 
behind. 

Conditions  Favoring  the  Accident. — The  conditions  associated  with 
pregnancy,  the  distension  and  engorgement  to  which  the  vessels  are  sub- 
jected, the  interference  M'ith  the  return  of  the  blood  by  the  pressure  of 
the  head  during  labor,  and  the  violent  efforts  of  the  patient,  afford  a 
ready  explanation  of  the  reason  why  a  vessel  may  be  predisposed  to  rup- 
ture and  admit  of  the  extravasation  of  blood. 

The  accident  is  fortunately  far  from  a  common  one,  although  a  suf- 
ficient number  of  cases  are  recorded  to  make  us  familiar  with  its  symp- 
toms and  risks.  The  dangers  attending  such  effusions  would  seem  to  be 
great,  if  the  statistics  given  by  those  who  have  written  on  the  sul)ject 
are  to  be  trusted.  Thus,  out  of  124  cases  collected  by  various  French 
authors,  44  proved  fatal.  Fordyce  Barker  points  out  that  since  the 
nature  and  approj^riate  treatment  of  the  accident  have  been  more  thor- 
oughly understood  the  mortality  has  been  much  lessened,  for  out  of  15 
cases  reported  by  Scanzoni,  only  1  died,  and  out  of  22  cases  he  had  him- 
self seen,  2  died ;  and  all  these  3  deaths  were  from  puerperal  fever,  and 
not  the  direct  result  of  the  accident.^ 

Situation  of  the  Blood- Effusion. — The  blood  may  be  effused  into  any 
part  of  the  pelvic  cellular  tissue  or  into  the  labia.  The  accident  most 
often  happens  during  labor  when  the  head  is  low  down  in  thejjelvis,  not 
unfrequently  just  as  it  is  about  to  escape  from  the  vulva.  Hence  the 
extravasation  is  more  often  met  with  low  down  in  the  vagina,  and  more 
frequently  in  one  of  the  labia  than  in  any  other  situation.  I  have  met 
with  a  case  in  which  I  had  every  reason  to  believe  that  an  extravasation 
of  blood  had  occurred  within  the  tissues  immediately  surrounding  the 

^  Amer.  Journ.  of  Obst.,  vol.  ix.  ^  The  Puerperal  Diseases,  p.  60. 


OBSTRUCTION  FROM  CONDITION  OF  SOFT  PARTS.  361 

cervix.  It  is  natural  to  suppose  that  a  varicose  condition  of  the  veins 
about  the  vulva  would  predispose  to  the  accident,  but  in  most  of  the 
recorded  examples  this  is  not  stated  to  have  been  the  case.  Still,  if  vari- 
cose veins  exist  to  any  marked  degree  some  anxiety  on  this  point  cannot 
but  be  felt. 

Time  of   Oceurrence. — The   thrombus    occasionally,    though    rarely, 
forms  before  delivery.     Most  commonly  it  first  forms  toward  the  end  I 
of  labor  or  after  the  birth  of  the  child.    In  the  latter  case  it  is  probable  ' 
that  the  laceration  in  the  vessels  occurred  before  the  birth  of  the  child, 
and  that  the  pressure  of  the  presenting  part  prevented  the  escape  of  any 
quantity  of  blood  at  the  time  of  laceration. 

Symptoms. — The  symptoms  are  not  by  any  means  characteristic.    Pain 
of  a  tearing  character,  occasionally  very  intense,  and  extending  to  the 
back  and  clown  the  thighs,  is  very  generally  associated  with  the  forma- 
tion of  the  thrombus.     If  a  careful  physical  examination  be  made,  the 
nature  of  the  case  can  readily  be  detected.    When  the  blood  escapes  into 
the  labium,  a  firm,  hard  swelling  is  felt,  which  has  even  been  mistaken 
for  the  foetal  head.     If  the  effusion  implicate  the  internal  parts  only, 
the  diagnosis  may  not  at  first  be  so  evident.    But  even  then  a  little  care 
should  prevent  any  mistake,  for  the  swelling  may  be  felt  in  the  vagina, 
and  may  even  form  an  obstacle  to  the  passage  of  the  child.     Cazeaux 
mentions  cases  in  which  it  was  so  extensive  as  to  compress  the  rectum 
and  urethra,  and  even  to  prevent  the  exit  of  the  lochia.     In  some  cases 
the  distension  of  the  tissues  is  so  great  that  they  lacerate,  and  then  hem- 
orrhage, sometimes  so  profuse  as  directly  to  imperil  the  life  of  the  patient, 
may  occur.     The  bursting  of  the  skin  may  take  place  some  time  subse-   i 
quent  to  the  formation  of  the  thrombus.     Constitutional  symptoms  will  I 
be  in  proportion  to  the  amount  of  blood  lost,  either  by  extravasation  or  | 
externally,  after  the  rupture  of  the  superficial  tissues.    Occasionally  they 
are  considerable,  and  are  the  same  as  those  of  hemorrhage  from  any_ 
cause. 

Terminations. — The  terminations  of  thrombus  are  either  spontaneous 
absorption,  which  may  occur  if  the  amount  of  blood  extravasated  be    • 
small ;  or  the  tumor  may  burst,  and  then  there  is  external  hemorrhage ;    : 
or  it  may  suppurate,  the  contained  coagula  being  discharged  from  the 
cavity  of  the  cyst ;  or,  finally,  sloughing  of  the  superficial  tissues  has^— 
occurred. 

Treatment. — The  treatment  must  naturally  vary  with  the  size  of  the 
thrombus  and  the  time  at  which  it  forms.  If  it  be  met  with  during 
labor,  unless  it  be  extremely  small  it  will  be  very  apt  to  form  an  obstruc- 
tion to  the  passage  of  the  child.  Under  such  circumstances  it  is  clearly 
advisable  to  terminate  the  labor  as  soon  as  possible,  so  as  to  remove  the 
obstacle  to  the  circulation  in  the  vessels.  For  this  purpose  the  forceps 
should  be  aj)plied  as  soon  as  the  head  can  be  easily  readied.  If  the 
tumor  itself  obstruct  the  passage  of  the  head  or  if  it  be  of  any  consider- 
able size,  it  will  be  necessary  to  incise  it  freely  at  its  most  prominent 
|)()int  and  turn  out  the  coagula,  controlling  the  hemorrhage  at  once  by 
iilliiig  tlie  (cavity  with  (!otton  wad(li,ng  saturated  in  a  solution  of  ])cr- 
c!il(»ri(l(!  «)f  iron,  whik;  at  the  same  time  digital  com|)r('ssi()ii  with  the 
tips  (jf  tiie  fiiig(!rs  is  kept  up.    By  this  means  pressure  is  applied  directly 


362  LABOR. 

to  the  ]>leeding  point,  and  the  hemorrhage  can  be  controlled  without 
diflficulty.  This  is  all  the  more  necessary  if  spontaneous  rupture  have 
taken  place,  for  then  the  loss  of  blood  is  often  profuse,  and  it  is  of  the 
utmost  importance  to  reach  the  site  of  the  hemorrhage  as  nearly  jis 
possible. 

If  the  thrombus  be  not  so  large  as  to  obstruct  delivery,  or  if  it  be  not 
detected  until  after  the  birth  of  the  child,  the  question  arises  whether 
the  case  should  not  be  left  alone,  in  the  hope  that  absorption  may  occur, 
as  in  most  cases  of  pelvic  hsematocele.  This  expectant  treatment  is 
advised  by  Cazeaux,  and  it  seems  to  be  the  most  rational  plan  we  can 
adopt.  True,  it  may  take  a  longer  time  for  the  patient  to  convalesce 
completely  than  if  the  coagula  were  removed  at  once  and  the  hemor- 
rhage restrained  by  pressure  on  the  bleeding  point ;  but  this  disadvan- 
tage is  more  than  counterbalanced  by  the  absence  of  risk  from  hemor- 
rhage, and  of  septicaemia  from  the  suppuration  that  must  necessarily 
follow.  Softening  and  suppuration  may  in  many  cases  occur  in  a  few 
days,  necessitating  operation,  but  the  vessels  will  then  be  probably 
occluded  and  the  risk  of  hemorrhage  much  lessened.  Dr.  Fordyce 
Barker,  however,  holds  the  opposite  opinion,  and  thinks  that  the  proper 
plan  is  to  open  the  thrombus  early,  controlling  the  hemorrhage  in  the 
manner  already  indicated,  unless  the  thrombus  is  situated  high  in  tlie 
vaginal  canal. 

Rish  of  Subsequent  Septiccemia. — Whenever  the  cavity  of  a  thrombus 
has  been  opened,  either  by  incision  or  by  spontaneous  softening  at  some 
time  subsequent  to  its  formation,  it  must  not  be  forgotten  that  there  is 
considerable  risk  of  septic  absorption.  To  avoid  this,  care  must  be 
taken  to  use  antiseptic  dressings  freely,  such  as  the  glycerin  of  carbolic 
acid,  applied  directly  to  the  part,  and  frequent  vaginal  injections  of 
diluted  Condy's  fluid.  Barker  lays  special  stress  on  the  importance 
of  not  removing  prematurely  the  coagula  formed  by  the  styptic  applica- 
tions for  fear  of  secondary  hemorrhage,  but  of  allowing  them  to  come 
away  spontaneously. 

[^PoIypus. — Large  uterine  polypi  may  act  as  serious  obstacles  to 
delivery.  When  sufficiently  long  in  pedicle,  a  polypus  may  be  extruded 
before  the  head  of  the  foetus.  The  tumor  may  also  be  detached  in  its 
expulsion,  or  may  be  removed  by  an  ecraseur  if  recognized  in  time :  it 
may  also  be  pushed  up  out  of  the  way  and  secured  by  bringing  down 
the  child.  I  once  replaced  a  large  polypus  that  was  extruded  before  the 
head,  and  the  woman  carried  it  two  years  longer ;  by  which  time,  being 
much  wasted  by  the  discharge,  she  made  up  her  mind  to  have  it 
removed. — Ed.] 


DYSTOCIA  FROM  FCETUS. 


363 


CHAPTER    XI. 

DIFFICULT    LABOR    DEPENDING    ON    SOME    UNUSUAL    CONDITION 

OF    THE    FCETUS. 


Fig.  125. 


Plural  Births. — The  subject  of  multiple  pregnancy  in  general  having 
already  been  fully  considered,  we  have  now  only  to  discuss  its  practical 
bearing  as  regards  labor.  Fortunately,  the  existence  of  twins  rarely 
gives  rise  to  any  serious  difficulty.  In  the  large  proportion  of  cases  the 
presence  of  a  second  foetus  is  not  suspected  until  the  birth  of  the  first, 
when  the  nature  of  the  case  is  at  once  apparent  from  the  fact  of  the 
uterus  remaining  as  large,  or  nearly  as  large,  as  it  was  before. 

There  may  possibly  be  some  delay  in  the  birth  of  the  first  child, 
inasmuch  as  the  extreme  distension  of  the  uterus  may  interfere  with  its 
thoroughly  efficient  action,  while,  in  addition,  the  uterine  pressure  is  not 
directly  conveyed  to  the  ovum  as  in  sin- 
gle births,  but  indirectly  through  the 
amniotic  sac  of  the  second  child  (Fig. 
125).  Such  delay  is  especially  apt  to 
arise  when  the  first  child  presents  by  the 
breech,  for  even  if  the  body  be  expelled 
spontaneously,  difficulty  is  likely  to  occur 
with  the  head,  since  the  uterus  does  not 
contract  upon  it,  as  is  ordinarily  the 
case.  Hence  the  intervention  of  the 
accoucheur  to  save  the  life  of  the  child 
by  the  extraction  of  the  head  will  be 
almost  a  matter  of  necessity. 

In  the  majority  of  cases,  after  the 
birth  of  the  first  child  there  is  a  tem- 
porary lull  in  the  pains,  which  soon 
recommence,  generally  in  from  ten  to 
twenty  minutes,  and  the  second  child  is 
rapidly  expelled,  for  on  account  of  the 
full  dilatation  of  the  soft  parts  there  is 
no  obstacle  to  its  delivery.  Sometimes 
there  is  a  considerable  interval  before  the 
pains  recur,  and  instances  are  recorded  in  which  even  several  days  have 
elapsed  between  the  births  of  the  two  children. 

Treatment. — In  most  cases  the  management  of  twins  does  not  differ 
from  that  of  ordinary  labor.  As  soon  as  we  are  certain  of  the  exist- 
ence of  a  second  f«?tus,  we  should  inform  the  bystanders,  but  not 
necessarily  the  nioth(!r,  to  whom  the  news  might  prove,  an  unpleasant 
and  ev(;n  dangerous  shock.  Then,  having  taken  care  to  tie  the  cord  of 
the  first  child  for  fear  of  vascular  communi(!ation  between  the  placentae, 
our  duty  is  to  wait  for  a  recurrence  of  the  ])ains.     If  these  come  on 


Twin   Pregnancy,   Breech   and   Head 

Presenting. 


364  LABOR. 

rapidly  and  the  presentation  of  the  second  fcetiis  be  normal,  its  birth  is 
managed  in  the  usual  way. 

3Ianagement  when  there  is  Delay  after  the  Birth  of  the  First  Child. — 
If  there  be  any  unusual  delay,  we  have  to  consider  the  proper  course  to 
pursue,  and  on  this  the  opinions  of  authorities  differ  greatly.  Some 
advise  a  delay  of  several  hours,  and  even  more,  if  pains  do  not  recur 
spontaneously  ;  while  others — Murphy,  for  example — recommend  that 
the  second  child  should  be  delivered  at  once.  Either  extreme  of  prac- 
tice is  probably  wrong,  and  the  safest  and  best  course  is  doubtless  the 
medium  one.  The  second  point  to  bear  in  mind  is,  that  in  multiple 
pregnancy,  on  account  of  the  extreme  distension  of  the  uterus,  there  is  a 
tendency  to  inertia,  and  consequently  to  post-partum  hemorrhage,  and 
that,  therefore,  it  is  better  that  the  birth  of  the  second  child  should  be 
delayed,  even  for  a  considerable  time,  rather  than  the  patient  should  run 
the  risk  attending  an  empty  and  uncontracted  uterus.  If,  however, 
uterine  action  be  present,  there  is  an  obvious  advantage  in  the  delivery 
of  the  second  child  before  the  dilatation  of  the  passages  passes  oif. 

Endeavors  should  be  made  to  Excite  Uterine  Action. — The  best  plan 
would  seem  to  be  if,  after  waiting  a  quarter  of  an  hour,  labor-pains  do 
not  occur,  to  try  and  induce  them  by  uterine  friction  and  pressure  and 
by  the  administration  of  a  dose  of  ergot,  to  which,  as  there  can  be  no 
obstacle  to  the  rapid  birth  of  the  second  child,  there  can  be  now  no 
objection.  The  membranes  of  the  second  child  should  always  be  rup- 
tured at  once  if  easily  within  reach,  as  one  of  the  speediest  means  of 
inducing  contraction.  If  no  progress  be  made,  and  speedy  delivery  be 
indicated — a  necessity  which  may  arise  either  from  the  exhausted  state 
of  the  patient,  the  presence  of  hemorrhage,  extremely  feeble  pulsations 
of  the  foetal  heart  (showing  that  the  life  of  the  second  child  is  endan- 
gered), or  malpresentations  of  the  second  foetus — turning  is  probably  the 
readiest  and  safest  expedient.  Under  such  circumstances  the  operation 
is  performed  with  great  ease,  since  the  passages  are  amply  dilated. 
After  bringing  down  the  feet,  the  birth  of  the  body  should  be  slowly 
effected,  with  the  view  of  ensuring  as  complete  subsequent  contraction 
as  possible.  If  the  head  has  descended  in  the  j^elvis,  of  course  turning 
is  impossible  and  the  forceps  must  be  applied. 

EifHculties  arising  from  Locked  Ticins. — Occasionally,  very  serious 
difficulties  arise  from  parts  of  both  foetuses  presenting  simultaneously, 
and  thus  impeding  the  entrance  of  either  child  into  the  pelvis,  or  getting 
locked  together,  so  as  to  render  delivery  impossible  without  artificial  aid. 
Such  difficulties  are  not  apt  to  arise  in  the  more  ordinary  cases,  in  which 
each  child  has  its  own  bag  of  membranes,  since  then  the  foetuses  are  kept 
entirely  separate,  but  in  those  in  which  the  twins  are  contained  in  a 
common  amniotic  cavity  or  in  which  both  sacs  have  burst  simultaneously. 
They  are  very  puzzling  to  the  obstetrician,  and  it  may  be  far  from  easy 
to  discover  the  cause  of  the  obstruction.  Xor  is  it  possible  to  lay  down 
any  positive  rules  for  their  management,  which  must  be  governed  to  a 
considerable  extent  by  the  circumstances  of  each  individual  case. 

Both  Heads  Presenting  Simultaneously. — Sometimes  both  heads  present 
simultaneously  at  the  brim,  and  then  neither  can  enter  unless  they  be 
unusually  small  or  the  pelvis  very  capacious,  when  both  may  descend ; 


DYSTOCIA  FROM  FCETUS. 


365 


or,  rather,  the  first  head  may  descend  low  into  the  pelvic  cavity,  and  then 
the  second  head  enters  the  brim  and  gets  jammed  against  the  thorax  of 
the  first  child  (Fig.  126).  Reimann^  relates  a  curious  example  of  this, 
in  which  he  delivered  the  head  first  with  the  forceps,  but  found  the  body 
would  not  follow,  and  on  examination  a  second  head  was  found  in  the 
pelvis.  He  then  applied  the  forceps  to  the  second  head ;  the  body  of 
the  first  child  was  then  born,  and  afterward  that  of  the  second.     Such  a 

Fig.  126. 


Shows  Head-Locking,  both  Children  Presenting  Head  First.    (After  Barnes.) 

mechanism  must  clearly  have  been  impossible  unless  the  pelvis  had  been 
extremely  large. 

Whenever  both  heads  are  felt  at  the  brim,  it  will  generally  be  found 
possible  to  get  one  out  of  the  way  by  appropriate  manipulation,  one  hand 
being  passed  into  the  vagina,  the  other  aiding  its  action  from  without. 
Then  the  forceps  may  be  applied  to  the  other  head,  so  as  to  engage  it  at 
once  in  the  pelvic  cavity.  If  both  have  actually  passed  into  the  pelvis, 
as  in  the  case  just  alluded  to,  the  difficulty  will  be  much  greater.  It 
will  generally  be  easier  to  push  up  the  second  head,  while  the  lower  is 
drawn  6ut  by  the  forceps,  than  to  deliver  the  second,  leaving  the  first 
in  situ. 

Foot  or  Hand  with  Head. — In  other  cases  a  foot  or  hand  may  descend 
along  with  the  head,  and  even  the  four  feet  may  present  simultaneously. 
The  rule  in  the  former  case  is  to  push  the  part  descending  with  the  head 
out  of  the  way,  and  in  the  latter  to  disengage  one  child  as  soon  as  pos- 
sible. Great  care  is  necessary,  or  we  might  possibly  bring  down  the  limbs 
of  separate  children, 

TiDo  Heads  interlockinr/  in  Head  and  Breech  Presentations. — The 
most  common  kind  of  difficulty  is  when  the  first  child  presents  by  the 
>  Arch.  f.  Gyncek.,  1871. 


M6 


LABOR. 


breech  and  is  delivered  as  far  as  the  head,  which  is  then  found  to  be 
locked  with  the  head  of  the  second  child,  which  has  descended  into  the 
pelvic  cavity  (Fig.  127). 

Here  it  is  clear  that  the  obstruction  must  be  very  great,  and,  unless 
the  children  are  extremely  small,  insuperable.  The  tirst  endeavor  should 
be  to  disentangle  the  head  :  this  is  sometimes  feasible  if  the  second  be 
not  deeply  engaged  in  the  pelvis,  and  the  hand  be  passed  up  so  as  to 
push  it  out  of  the  way.  This  will  but  rarely  succeed  :  then  it  may  be 
possible  to  apply  the  forceps  to  the  second  head  and  drag  it  past  the  body 

Fig.  127. 


Shows  Head-locking,  First  Child  coming  Feet  First ;  Impaction  of  Heads  from  Wedging  in 

Brim.    (After  Barnes.) 

D.  Apex  of  wedge,     e,  c.  Base  of  weflge  which  cannot  enter  brim,     a,  b.  Line  of  decapitation  to 

decompose  wedge  and  enable  head  of  second  child  to  pass. 

of  the  first  child ;  and  this  is  the  method  recommended  by  Reimann, 
who  has  written  an  excellent  paper  on  the  subject.^  Generally,  the  sacri- 
fice of  one  of  the  children  is  essential,  and  as" the  body  of  the  first  child 
must  have  been  born  for  some  time,  it  is  probable  that  the  pressure  to 

^American  Journal  of  Obstetrics,  January,  1877. 


DYSTOCIA    FROM  FCETUS.  367 

which  it  has  been  subjected  will  have  already  imperilled,  if  it  has  not 
destroyed,  its  life,  and  therefore  the  plan  usually  recommended  is  to 
decapitate.  This  can  easily  be  done  with  scissors  or  a  wire  ecraseur, 
after  which  the  second  child  is  expelled  without  difficulty,  leaving  the 
head  of  the  first  in  utero  to  be  subsequently  dealt  with. 

Another  mode  of  managing  these  cases  is  to  perforate  the  upper  head 
and  draw  it  past  the  lower  with  the  cephalotribe  or  craniotomy-forceps. 
This  plan  has  the  disadvantage  of  probably  sacrificing  both  children, 
since  the  other  child  can  hardly  survive  the  pressure  and  delay,  whereas 
the  former  plan  gives  the  second  child  a  fair  chance  of  being  born  alive. 

Double  Monsters. — In  connection  with  the  subject  of  twin  labor  we 
may  consider  those  rare  cases  in  which  the  bodies  of  the  foetuses  are  par- 
tially fused  together.  The  mechanism  and  management  of  delivery  in 
cases  of  double  monstrosity  have  attracted  comparatively  little  attention, 
no  doubt  because  authors  have  considered  them  matters  of  curiosity 
merely,  rather  than  of  practical  importance. 

The  frequent  occurrence  of  such  monstrosities  in  our  museums,  and 
the  numerous  cases  scattered  through  our  periodical  literature,  are  suf- 
ficient to  show  that  they  are  not  so  very  rare  as  we  might  be  inclined  to 
imagine  ;  and,  as  they  are  likely  to  give  rise  to  formidable  difficulties  in 
delivery,  it  cannot  be  unimportant  to  have  a  clear  idea  of  the  usual 
course  taken  by  nature  in  effecting  such  births,  with  a  view  of  enabling 
us  to  assist  in  the  most  satisfactory  manner  should  a  similar  case  come 
under  our  observation. 

Unfortunately,  the  authors  who  have  placed  on  record  the  birth  of 
double  monsters  have  generally  occupied  themselves  more  with  a  descrip- 
tion of  the  structural  peculiarities  of  the  foetuses  than  with  the  mechan- 
ism of  their  delivery ;  so  that,  although  the  cases  to  be  met  with  in 
medical  literature  are  very  numerous,  comparatively  few  of  them  are  of 
real  value  from  an  obstetric  point  of  view.  Still,  I  have  been  able  to 
collect  the  details  of  a  considerable  number^  in  which  the  history  of  the 
labor  is  more  or  less  accurately  described ;  and  doubtless  a  more  exten- 
sive research  would  increase  the  list. 

For  obstetric  purposes  we  may  confine  our  attention  to  four  principal 
varieties  of  double  monstrosity  which  are  met  with  far  more  frequently 
than  any  others.     These  are  : 

A.  Two  nearly  separate  bodies  united  in  front,  to  a  varying  extent, 
by  thorax  or  abdomen. 

B.  Two  nearly  separate  bodies  united  back  to  back  by  the  sacrum  and 
lower  part  of  the  spinal  column. 

C.  Dicephalous  monsters,  the  bodies  being  single  below,  but  the  heads 
separate. 

D.  The  bodies  separate  below,  but  the  heads  partially  united. 

This  classification  by  no  means  includes  all  the  varieties  of  monsters 
that  we  may  meet  with.  It  does,  however,  include  all  that  are  likely  to 
give  rise  to  much  difficulty  in  delivery ;  and  all  the  cases  I  have  col- 
lected may  be  placed  under  one  of  these  divisions. 

The  first  point  that  strikes  us  in  looking  over  the  history  of  these 
deliveries  is  the  frequency  with  which  they  have  been  terminated  by  the 

'  Obat.  Trans.,  vol.  viii. 


368  LABOR. 

natural  powers  alone,  without  any  assistance  on  the  part  of  the  accou- 
cheur. Thus,  out  of  the  31  cases,  no  less  than  20  were  delivered  nat- 
urally, and  apparently  without  much  trouble.  Nothing  can  better 
show  the  wonderful  resources  of  nature  in  overcoming  difficulties  of  a 
very  formidable  kind. 

It  is  pretty  generally  assumed  by  authors  that  the  children  are  neces- 
sarily premature,  and  therefore  of  small  size,  and  that  delivery  before 
the  full  term  is  rather  the  rule  than  the  exception.  Duges  states  that 
the  children  are  often  dead,  and  that  putrefaction  has  taken  place,  which 
facilitates  their  expulsion.  Both  these  assumptions  seem  to  me  to  have 
been  made  without  sufficient  authority,  and  not  to  be  borne  out  by  the 
recorded  facts.  In  only  1  of  the  31  cases  is  it  mentioned  that  the  chil- 
dren were  premature ;  nor  is  there  any  sufficient  reason  that  I  can  see 
why  labor  should  commence  before  the  full  term  of  gestation. 

Class  A. — By  far  the  greatest  number  are  included  in  the  first  class — 
that  in  which  the  bodies  are  nearly  separate,  but  united  by  some  part  of 
the  thorax  or  abdomen.  This  is  the  division  which  includes  the  cele- 
brated Siamese  Twins,  an  account  of  whose  birth,  I  may  observe,  I 
have  not  been  able  to  discover.'  Out  of  the  31  cases,  19  come  under 
this  heading.  The  details  of  the  labor  are  briefly  as  follows  :  1  died 
undelivered  ;  8  were  terminated  by  the  natural  powers,  in  3  of  which 
the  feet,  and  in  3  the  head,  presented ;  in  2  the  presentation  is  doubtful ; 
6  were  delivered  by  turning  or  by  traction  on  the  lower  extremities ;  4 
were  delivered  instrumentally. 

Footling  Presentation  is  the  most  Favorable. — The  details  of  the  cases 
in  which  the  feet  presented  or  in  which  turning  was  performed  clearly 
show"  that  footling  presentation  was  by  far  the  most  favorable,  and  it  is 
fortunate  the  feet  often  present  naturally.  The  inference  of  course  is, 
that  version  should  be  resorted  to  whenever  any  other  presentation  is 
met  with  in  cases  of  double  monstrosity  of  this  type;  but,  unfortu- 
nately, this  rule  could  rarely  be  carried  into  execution,  since  we  possess 
no  means  of  diagnosing  the  junction  of  the  foetuses  at  a  sufficiently  early 
stage  of  labor  to  admit  of  turning  being  performed.  It  is  only  under 
exceptionally  favorable  circumstances  that  this  can  be  done ;  as,  for 
example,  in  a  case  recorded  by  Molas,^  in  which  both  heads  presented, 
but  neither  would  enter  the  brim  of  the  pelvis. 

The  Chief  Difficulty  is  in  the  Delivery  of  the  Heads. — The  great  diffi- 
culty must,  of  course,  be  in  the  delivery  of  the  heads,  for  in  all  the  record- 
ed cases,  with  one  exception,  the  bodies  have  passed  through  the  pelvis 
parallel  to  each  other  with  comparative  ease  until  the  necks  have  ap- 
peared, and  then,  as  a  rule,  they  could  be  brought  no  farther.  It  is 
clear  that  the  remainder  of  the  foetuses  could  no  longer  pass  simultane- 

^  The  mother  of  these  twins  was  a  Chinese  half-breed,  short,  and  with  a  broad  pelvis, 
and  had  borne  several  children  previously.  She  stated  on  several  occasions,  in  conver- 
sation with  parties  in  Siam,  that  the  twins  were  born  reversed,  the  feet  of  one  being 
followed  by  the  head  of  the  other,  and  that  they  were  very  small  and  feeble  at  birth 
and  for  several  months  afterward.  The  twins  confirmed  this  statement  by  affirming 
that  they  could,  when  little  boys  at  play  on  the  ground,  turn  themselves  end  for  end 
j^pon  the  ensiforrn  attachment  up  to  the  age  of  ten  or  twelve,  the  attachment  being 
then  soft  and  pliable  (Harris's  note  to  second  American  edition). 

^  ]\lem.  de  V Academic,  vol.  i. 


DYSTOCIA   FROM  FfETUS.  369 

ously,  and  were  direct  traction  continued  the  heads  would  be  inextrica- 
bly fixed  above  the  brim.  In  accordance  with  the  direction  of  the  pelvic 
axes  the  posterior  head  must  iirst  engage  in  the  inlet ;  and  in  order  to 
effect  this  it  will  be  necessary  to  carry  the  bodies  of  the  children  well 
over  the  abdomen  of  the  mother.  This  seems  to  be  a  point  of  primary 
importance.  It  would  also  be  advisable  to  see  that  the  bodies  are  made 
to  pass  through  the  pelvis  with  their  backs  in  the  oblique  diameter.  By 
this  means  more  space  is  gained  than  if  the  backs  were  placed  antero- 
posteriorly,  m' hile  at  the  same  time  there  is  less  chance  of  the  heads 
hitching  against  the  promontory  of  the  sacrum  and  symphysis  pubis, 
^vhich  otherwise  would  be  very  apt  to  occur. 

Mode  of  Delivery  ivhen  the  Head  Presents. — When  the  head  presents, 
and  the  labor  is  terminated  by  the  natural  powers,  delivery  seems  to  be 
accomplished  in  one  of  two  ways. 

In  the  first  and  more  common  the  head  and  shoulders  of  one  child 
are  born,  its  breech  and  legs  being  subsequently  pushed  through  the 
pelvis  by  a  process  similar  to  that  of  spontaneous  evolution ;  and 
afterward  the  second  child  probably  passes  footling  without  much 
difficulty. 

Barkow  relates  a  case  in  which  both  heads  were  delivered  by  the 
forceps,  the  bodies  subsequently  passing  simultaneously.  Two  similar 
instances  are  recorded  in  the  third  and  sixth  volumes  of  the  Obstetrical 
Transactions.  When  delivery  takes  place  in  this  manner  the  head  of 
the  second  child  must  fit  into  the  cavity  formed  by  the  neck  of  the  first, 
and  the  pelvis  must  necessarily  be  sufficiently  roomy  to  admit  of  the 
expulsion  of  the  head  of  the  second  child,  while  its  cavity  is  diminished 
in  size  by  the  presence  of  the  neck  and  shoulders  of  the  first.  Either 
of  these  processes  must  obviously  require  exceptionally  favorable  con- 
ditions as  regards  the  size  of  the  child  and  the  pelvis,  and  the  difficulty 
in  the  way  of  delivery  must  be  much  greater  than  when  the  lower 
extremities  present.  Therefore,  I  think  the  rule  should  be  laid  down 
that  when  the  nature  of  the  case  is  made  out  (and  for  the  purpose  of 
accurate  diagnosis  a  complete  examination  under  ansesthesia  should  be 
practised)  turning  should  be  performed  and  the  feet  brought  down. 

Midilation  of  the  Foetuses, — In  the  event  of  its  being  found  impossi- 
])le  to  effect  delivery  after  a  considerable  portion  of  the  bodies  is  born, 
no  resource  remains  but  the  mutilation  of  the  body  of  one  child  so  as  to 
admit  of  the  passage  of  the  other.  This  was  found  necessary  in  one 
case  in  which  the  children  presented  by  the  feet  and  were  born  as  far  as 
the  thorax,  but  could  get  no  farther.  The  body  of  the  anterior  child 
was  removed  by  a  circular  incision  as  far  as  it  had  been  expelled,  which 
allowed  tlic  remaining  portion,  consisting  of  tlie  head  and  shoulders,  to 
rc-cntcr  tlie  uterus  :  after  this  the  posterior  child  was  easily  extracted, 
and  tlie  nuitilatcd  foetus  followed  witliout  difficulty. 

Class  B. — In  Class  B,  in  which  the  chihlren  are  united  back  to  back, 
3  cases  are  recorded,  all  of  which  were  delivered  by  the  natural  powers. 
One  of  these  is  the  case  of  Judith  and  Heldne,  the  celebrated  Hungarian 
twins,  M'ho  lived  to  the  age  of  twenty-one.  Heldne  was  born  as  far  as 
the  unil)ilicus,  and  after  the  la|)s('  of  three  hoin-s  her  breech  and  legs  de- 
sc^iiided,  Judith  was  expelled  immediately  afterward,  her  feet  descend- 
24 


370  LABOR. 

injo;  lir.st.  [']     Exactly  the  same  process  (X'curred  in  a  case  described  by 
M.  Norman,  the  children  being  also  born  alive,  and  dying  on  the  ninth 

Labor  is  Easier  than  in  Class  A. — It  is  probable  that  labor  is  easier 
in  this  class  of  double  monsters  than  in  the  former,  because  the  children 
are  so  joined  that  there  is  no  necessity  for  the  bodies  to  be  parallel  to 
each  other  during  birth  when  the  head  presents,  and  after  the  birth  of 
the  head  and  shoulders  of  the  first  child  its  breech  and  lower  extremities 
are  evidently  pushed  down  and  expelled  by  a  process  of  spontaneous 
evolution.  If  the  feet  originally  presented,  the  mechanism  of  delivery 
and  the  rules  to  be  followed  would  be  the  same  as  in  Class  A ;  but  the 
difficulty  would  probably  be  greater,  since  the  juncture  is  not  so  flexible, 
and  a  more  complete  parallelism  of  the  bodies  would  be  necessary  during 
extraction. 

Glass  C. — In  Class  C,  that  of  the  dicephalous  monster,  I  have  found 
the  description  of  the  birth  of  8  cases,  3  of  which  were  terminated  by 
the  natural  powers.  In  2  of  these  the  process  of  evolution  was  the 
main  agent  in  delivery,  one  head  being  born  and  becoming  fixed  un- 
der the  arch  of  the  pubes,  the  body  being  subsequently  pushed  past 
it,  and  the  second  head  following  without  difficulty.  This  process  tail- 
ing, the  proper  course  is  to  decapitate  the  first-born  head,  and  then 
bring  down  the  feet  of  the  child,  when  delivery  can  be  accomplished 
with  ease.  This  was  the  course  adopted  in  2  out  of  the  8  cases ;  aiid  it 
may  be  done  with  the  less  hesitation  since,  from  their  structural  pecu- 
liarities, it  is  exceedingly  improbable  that  monsters  of  this  kind  should 
survive.  In  the  third  case,  terminated  naturally,  the  heads  Avere  said 
to  have  been  born  simultaneously,  but  it  seems  probable  that  the  one 
head  lay  in  the  hollow  formed  by  the  neck  of  the  other,  and  so  rapidly 
followed  it.  If  the  feet  presented,  the  case  may  be  managed  in  the  same 
manner  as  in  Class  A. 

Class  D. — Monstrosities  of  Class  D,  in  which  the  heads  are  united, 
the  bodies  being  distinct,  appear  to  be  the  most  uncommon  of  all,  and  I 
can  find  the  description  of  delivery  in  only  2  cases.  One  of  these  gave 
rise  to  great  difficulty ;  the  labor  in  the  other  was  easy.  We  should 
scarcely  anticipate  much  difficulty  in  the  birth  of  monsters  of  this  type, 
for  if  the  head  presented  and  would  not  pass,  we  should  naturally  per- 
form craniotomy  ;  and  if  the  bodies  came  first,  the  delivery  of  the  mon- 
strous head  could  readily  be  accomplished  by  perfiiration. 

Result  to  the  Mothers. — The  result  to  the  mothers  in  all  these  cases 
seems  to  have  been  very  favorable.  There  is  only  one  in  which  the 
death  of  the  mother  is  recorded  ;  and  although  in  many  the  result  is 
not  mentioned,  we  may  fairly  assume  that  recovery  took  place. 

Among  difficulties  in  labor,  some  of  the  most  important  are  due  to 
morbid  conditions  of  the  foetus  itself. 

Intva-uterine  Hydrocephalus. — Of  these,  the  most  common  as  well  as 

[^  The  celeliratecl  colored  Carolina  twins,  born  July  11,  1851,  and  still  living,  were 
bronp:ht  into  the  world  by  the  same  method,  but  the  mother,  liaving  a  large  pelvis, 
"  had  a  brief  and  easy"  delivery.  The  larger  of  the  two  girls  also  came  tirst,  as  in  the 
Tzoni  case  of  1701.  These  twins  are  now  (1885)  twelve  years  older  than  the  Hunga- 
rian sisters  were  at  death,  being  33  years  of  age. — Ed.] 


DYSTOCIA    FROM  FCETUS. 


371 


the  most  serious  is  caused  by  intra-uterine  hydrocephalus  (giving  rise  to 
a,  collection  of  watery  fluid  within  the  cranium),  by  which  the  dimen- 
sions of  the  child's  head  are  enormously  increased  and  the  due  relations 
between  it  and  the  pelvic  cavity  entirely  destroyed  (Fig.   128). 

Its  Danger  both  as  Megards  the  Mother  and  Child. — Fortunately,  this 
disease  is  of  comparatively  rare  occurrence,  for  it  is  one  of  great  gravity  j 
both  as  regards  the  mother  and  child.  As  regards  the  mother,  the  seri-  1 
ous  character  of  the  complication  is  proved  by  the  statistics  of  Dr. 
Keiller  of  Edinburgh,  who  found  that  out  of  74  cases  no  less  than  16 
were  accompanied  by  rupture  of  the  uterus.  The  reason  of  the  danger 
to  which  the  mother  is  subjected  is  obvious.  In  some  few  cases,  indeed, 
the  head  is  so  compressible  that,  provided  the  amount  of  contained  fluid 

Fia.  128. 


Labor  Impeded  by  Hydrocephalus. 

be  small,  it  may  be  sufficiently  diminished  in  size  by  the  moulding  to 
which  it  is  subjected  to  admit  of  its  being  squeezed  through  the  pelvis. 
In  the  majority  of  cases,  however,  the  size  of  the  head  is  too  great  for 
this  to  occur.  The  uterus  therefore  exhausts  itself,  and  may  even  rup- 
ture, in  the  vain  endeavor  to  overcome  the  obstacle ;  while  the  large  and 
distended  head  presses  firmly  on  the  cervix  or  on  the  pelvic  tissues  if  the 
OS  be  dilated,  and  all  the  evil  eifects  of  prolonged  compression  are  apt  to 
follow. 

Its  JJtagnosis  is  not  always  Easy. — The  diagnosis  of  intra-uterine 
hydrocephalus  is  by  no  means  so  easy  as  the  desc^ription  in  obstetric 
works  would  l(!ad  us  to  believe.  It  is  trno,  thiit  the,  head  is  much  larger 
and  mon;  rounded  in  its  (contour  than  tlu;  healthy  fictal  cram'uni,  and 
also  tliat  tlu;  suturcis  and  fontanc^lles  an;  mon;  wide,  and  admit  occasion- 
ally of  flnctnation  being  |)crceivcd  throngli  them.  Still,  it  is  to  be 
remem})ered  that  the  h(!ad  is  always  arrested  above  the  brim,  where  it  is 
consequently  high  uj)  and  difficult  to  reach,  and  where  these  peculiarities 


372  LABOR. 

are  made  out  with  much  difficulty.  As  a  matter  of  fact,  the  true  nature 
of  the  case  is  comparatively  rarely  discovered  before  delivery ;  thus, 
Chaussier^  found  that  in  more  than  one-half  of  the  cases  he  collected 
an  erroneous  diagnosis  had  been  made. 

Method  of  Diagnosis. — Whenever  we  meet  with  a  case  in  which  either 
the  history  of  previous  labor  or  a  careful  examination  convinces  us  that 
there  is  no  obstacle  due  to  pelvic  deformity,  in  which  the  pains  are 
strong  and  forcing,  but  in  which  the  head  persistently  refuses  to  engage 
in  the  brim,  we  may  fairly  surmise  the  existence  of  hydrocephalus. 
Kothing,  however,  short  of  a  careful  examination  under  anaesthesia,  the 
whole  hand  being  passed  into  the  vagina  so  as  to  explore  the  presenting 
part  thoroughly,  will  enable  us  to  be  quite  sure  of  the  existence  of  this 
complication.  Under  these  circumstances  such  a  complete  examination 
is  not  only  justified,  but  imperative  ;  and  when  it  has  been  made  the  dif- 
ficulties of  diagnosis  are  lessened,  for  then  we  may  readily  make  out  the 
large  round  mass,  softer  and  more  compressible  than  the  healthy  head, 
the  Mddely-separated  sutures,  and  the  fluctuating  fontanelles. 

Pelvio  Presentations  are  Frequently  met  with. — In  a  considerable  pro- 
portion of  cases — as  many,  it  is  said,  as  1  out  of  5 — the  foetus  presents 
by  the  breech.  The  diagnosis  is  then  still  more  difficult ;  for  the  labor 
progresses  easily  until  the  shoulders  are  born,  when  the  head  is  com- 
pletely arrested,  and  refuses  to  pass  with  any  amount  of  traction  that  is 
brought  to  bear  on  it.  Even  the  most  careful  examination  may  not 
enable  us  to  make  out  the  cause  of  the  delay,  for  the  finger  will  impinge 
on  the  comparatively  firm  base  of  the  skull,  and  may  be  unable  to  reach 
the  distended  portion  of  the  cranium.  At  this  time  abdominal  palpa- 
tion might  throw  some  light  on  the  case,  for,  the  uterus  being  tightly 
contracted  round  the  head,  we  might  be  able  to  make  out  its  unusual 
dimensions.  The  wasted  and  shrivelled  appearance  of  the  child's  body, 
which  so  often  accompanies  hydrocephalus,  would  also  arouse  suspicion  as 
to  the  cause  of  delay.  On  the  ^hole,  such  cases  may  be  fairly  assumed 
to  be  less  dangerous  to  the  mother  than  Avhen  the  head  jDresents ;  for  in 
the  latter  the  soft  parts  are  apt  to  be  subjected  to  prolonged  pressure  and 
contusion,  while  in  the  former  delay  does  not  commence  till  after  the 
shoulders  are  born,  and  then  the  character  of  the  obstacle  would  be 
sooner  discovered  and  appropriate  means  earlier  taken  to  overcome  it. 

Treatment. — The  treatment  is  simple,  and  consists  in  tapping  the 
head,  so  as  to  allow  the  cranial  bones  to  collapse.  There  is  the  less 
objection  to  this  course  since  the  disease  almost  necessarily  precludes  the 
hope  of  the  child's  surviving.  The  as])irator  would  draw  oif  the  fluid 
effectually,  and  would  at  least  give  the  child  a  chance  of  life  ;  and  under 
certain  circumstances  the  birth  of  a  child  who  lives  for  a  short  time  only 
may  be  of  extreme  legal  importance.  ]\Iore  generally  the  perforator 
wall  be  used,  and  as  soon  as  it  has  penetrated  a  gush  of  fluid  will  at  once 
verify  the  diagnosis.  Schroeder  recommends  that  after  perforation 
turning  should  be  performed,  on  account  of  the  difficulty  with  which  the 
flaccid  head  is  propelled  through  the  pelvis.  This  seems  a  very  unne- 
cessary complication  of  an  already  sufficiently  troublesome  case.  As  a 
rule,  when  once  the  fluid  has  been  evacuated,  the  pains  being  strong,  as 

^  Gazette  medicate,  1864. 


DYSTOCIA   FROM  FCETUS.  373 

they  generally  are,  no  delay  need  be  apprehended.  Should  the  head  not 
come  down,  the  cephalotribe  may  be  applied,  which  takes  a  firmer  grasp 
than  the  forceps,  and  enables  the  head  to  be  crushed  to  a  very  small  size 
and  readily  extracted. 

Treatment  when  the  Breech  Presents. — When  the  breech  presents,  the 
head  must  be  perforated  through  the  occipital  bone ;  and  generally  this 
may  be  accomplished  behind  the  ear  without  much  difficulty.  In  a  case 
of  Tarnier's^  the  vertebral  column  was  divided  by  a  bistoury,  and  an 
elastic  male  catheter  introduced  into  the  vertebral  canal,  through  which 
the  intra-cranial  fluid  escaped,  the  labor  being  terminated  spontaneously. 
In  any  case  in  which  it  is  found  difficult  to  reach  the  skull  with  the  per- 
forator this  procedure  should  certainly  be  tried. 

Other  forms  of  dropsical  effusion  may  give  rise  to  some  difficulty,  but 
by  no  means  so  serious.  In  a  few  rare  cases  the  thorax  has  been  so  dis- 
tended with  fluid  as  to  obstruct  the  passage  of  the  child.  Ascites  is 
somewhat  more  common,  and  occasionally  the  child's  bladder  is  so  dis- 
tended with  urine  as  to  prevent  the  birth  of  the  body.  The  existence 
of  any  of  these  conditions  is  easily  ascertained ;  for  the  head  or  breech, 
whichever  happens  to  j)resent,  is  delivered  without  difficulty,  and  then 
the  rest  of  the  body  is  arrested.  This  will  naturally  cause  the  practi- 
tioner to  make  a  careful  exploration,  wdien  the  cause  of  the  delay  will  be 
detected. 

The  treatment  consists  in  the  evacuation  of  the  fluid  by  puncture.  In 
the  case  of  ascites  this  should  always  be  done,  if  possible,  by  a.  fine  trocar 
or  aspirator,  so  as  not  to  injure  the  child.  This  is  all  the  more  import- 
ant since  it  is  impossible  to  distinguish  a  distended  bladder  from 
ascites,  and  an  opening  of  any  size  into  that  viscus  might  prove  fatal, 
whereas  aspiration  would  do  little  or  no  harm,  and  would  prove  quite 
as  efficacious. 

Foetal  Tumors  Obstructing  Delivery. — Certain  fcetal  tumors  may  occa- 
sion dystocia,  such  as  malignant  growths  or  tumors  of  the  kidney,  liver, 
or  spleen.  Cases  of  this  kind  are  recorded  in  most  obstetric  works. 
Hydro-encephalocele  or  hydro-rachitis,  depending  on  defective  forma- 
tion of  the  cranial  or  spinal  bones,  with  the  formation  of  a  large  pro- 
truding bag  of  fluid,  is  not  very  rare.  The  diagnosis  of  all  such  cases 
is  somewhat  obscure,  nor  is  it  possible  to  lay  down  any  definite  rules  for 
their  management,  which  must  vary  according  to  the  particular  exigen- 
cies. The  tumors  are  rarely  of  sufficient  size  to  prove  formidable  obsta- 
cles to  delivery,  and  many  of  them  are  very  compressible.  This  is 
specially  the  case  with  the  spina  bifida  and  similar  cystic  growths. 
Puncture,  and  in  the  more  solid  growths  of  the  abdomen  or  thorax 
evisa^ration,  may  be  required. 

Other  Conr/enital  Deformities. — Other  deformities,  such  as  the  anen- 
cephalous  ffetus,  or  defective  development  of  tlie  thorax  or  abdominal 
pari(!tos  with  protrusion  of  the  viscera,  arc  not  likely  to  cause  difficulty, 
but  tliey  may  nnicli  (Mubarrass  the  diagnosis  by  the  strange  and  unusual 
presentation  that  is  felt.  If  in  any  case  of  doubt  a  full  and  careful 
examination  be  undertaken,  intnjducing  the  whole  hand  if  necessary,  no 
serious  mistake  is  likely  to  be  made. 

'  riergott,  Maladie.i  FcelnUs  (jui  peiivml  fdlre  o/)slni-/e  il  I'/icronrliement,  Paris,  1S7S. 


374  LABOR. 

Dystocia  from  Excessive  Development  of  tJie  Foetus. — In  addition  to 
dystocia  from  morbid  conditions  of  the  foetus,  difficulties  may  arise  from 
its  undue  development,  and  especially  from  excessive  size  and  advanced 
ossification  of  the  skull.  This  last  is  especially  likely  to  cause  delay. 
Even  the  slight  difference  in  size  between  the  male  and  female  head  was 
found  by  Simpson  to  have  an  appreciable  effect  in  increasing  the  diffi- 
culty of  labor  when  the  statistics  of  a  large  number  of  cases  were  taken 
into  account ;  for  he  proved  beyond  doubt  that  the  difficulties  and  cas- 
ualties of  labor  occurred  in  decidedly  larger  proportion  in  male  than  in 
female  births.  Other  circumstances  besides  sex  have  an  important  effect 
on  the  size  of  the  child.  Thus,  Duncan  and  Hecker  have  shown  that 
it  increases  in  proportion  to  the  age  of  the  mother  and  the  frequency  of 
the  labors  ;  while  the  size  of  the  parents  has  no  doubt  also  an  important 
bearing  on  the  subject. 

Although  these  influences  modify  the  results  of  labor  en  masse,  they 
have  little  or  no  practical  bearing  on  any  particular  case,  since  it  is  im- 
possible to  estimate  either  the  size  of  the  head  or  the  degree  of  its  ossi- 
fication until  labor  is  advanced. 

Treatment. — When  labor  is  retarded  by  undue  ossification  or  large  size 
of  the  head,  the  cause  must  be  treated  on  the  same  general  principles 
which  guide  us  when  the  want  of  proportion  is  caused  by  pelvic  contrac- 
tion. Hence,  if  delay  arise  which  the  natural  powers  are  insufficient  to 
overcome,  it  will  selctom  happen  that  the  disproportion  is  too  great  for 
the  forceps  to  overcome.  If  we  fail  to  deliver  by  it,  no  resource  is  left 
but  perforation. 

Large  Size  of  the  Body  rarely  causes  Delay. — Large  size  of  the  body 
of  the  child  is  still  more  rarely  a  cause  of  difficulty,  for  if  the  head  be 
born  the  compressible  trunk  will  almost  always  follow.  Still,  a  few 
authentic  cases  are  on  record  in  which  it  M^as  found  impossible  to  extract 
the  foetus  on  account  of  the  unusual  bulk  of  its  shoulders  and  thorax. 
Should  the  body  remain  firmly  impacted  after  the  birth  of  the  head,  it 
is  easy  to  assist  its  delivery  by  traction  on  the  axillse,  by  gently  aiding 
the  rotation  of  the  shoulders  into  the  antero-posterior  diameter  of  the 
pelvic  cavity,  and,  if-  necessary,  by  extracting  the  arms,  so  as  to  lessen 
the  bulk  of  the  part  of  the  body  contained  in  the  pelvis.  Hicks  relates 
a  case  in  which  evisceration  was  required  for  no  other  apparent  reason 
than  the  enormous  size  of  the  body.  The  necessity  for  any  such  extreme 
measure  must  of  course  be  of  the  greatest  possible  rarity,  and  it  is  quite 
exceptional  for  difficulty  from  this  source  to  be  beyond  the  powers  of 
nature  to  overcome. 


DEFORMITIES  OF  THE  PELVIS.  375 


CHAPTER   XII. 

DEFOEMITIES  OF  THE  PELVIS. 

Importance  of  the  Subject. — Deformities  of  the  pelvis  form  one  of  the 
most  important  subjects  of  obstetric  study,  for  from  them  arise  some  of 
the  gravest  difficulties  and  dangers  connected  with  parturition.  A  know- 
ledge, therefore,  of  their  causes  and  effects,  and  of  the  best  mode  of  detect- 
ing them,  either  during  or  before  labor,  is  of  paramount  necessity ;  but 
the  subject  is  far  from  easy,  and  it  has  been  rendered  more  difficult  than 
it  need  be  from  over-anxiety  on  the  part  of  obstetricians  to  force  all 
varieties  of  pelvic  deformities  within  the  limits  of  their  favorite  classi- 
fication. 

Dificulties  of  Classification. — Many  attempts  in  this  direction  have 
been  made,  some  of  which  are  based  on  the  causes  on  which  the  deformi- 
ties depend,  others  on  the  particular  kind  of  deformity  produced.  The 
changes  of  form,  however,  are  so  various  and  irregular,  and  similar  or 
apparently  similar  causes  so  constantly  produce  different  effects,  that  all 
such  endeavors  have  been  more  or  less  unsuccessful.  For  example,  we 
find  that  rickets  (of  all  causes  of  pelvic  deformity  the  most  important) 
generally  produces  a  narrowing  of  the  conjugate  diameter  of  the  brim, 
while  the  analogous  disease,  osteo-malacia,  occurring  in  adult  life,  gener- 
ally produces  contraction  of  the  transverse  diameter,  with  approximation 
of  the  pubic  bones  and  relative  or  actual  elongation  of  the  conjugate 
diameter.  We  might,  therefore,  be  tempted  to  classify  the  results  of 
these  two  diseases  under  separate  heads,  did  we  not  find  that  when  rickets 
affects  children  who  are  running  about  and  subject  to  mechanical  influ- 
ences similar  to  those  acting  upon  patients  suffering  from  osteo-malacia, 
a  form  of  pelvis  is  produced  hardly  distinguishable  from  that  met  with 
in  the  latter  disease,  which  by  some  authors  is  described  as  the  pseudo- 
osteo-malacic. 

Host  Simple  Classification. — On  the  whole,  therefore,  the  most  simple 
as  well  as  the  most  scientific  classification  is  that  which  takes  as  its  basis 
the  particular  seat  and  nature  of  the  deformity.  Let  us  first  glance  at 
the  most  common  causes. 

Causes  of  Pelvic  Deformity. — The  key  to  the  particular  shape  assumed 
by  a  deformed  pelvis  will  be  found  in  a  knowledge  of  the  circumstances 
wliich  lead  to  its  regular  development  and  normal  shape  in  a  state  of 
lieaUh.  The  changes  produced  may,  almost  invariably,  be  traced  to  the 
action  of  the  same  causes  whicli  jiroduce  a  normal  pelvis,  but  whi(!h, 
under  certain  diseased  conditions  of  the  bones  or  articulations,  induce  a 
more  or  less  serious  alteration  in  form.  These  have  been  already 
described  in  discussing  the  noi'inal  anatomy  of  the  pelvis;  and  it  will 
be  reniemb(;r(;d  that  they  are  chiefly  the  weight  of  the  body  transmitted 
to  the  iliac  bones  through  the  sacro-iliac  joints,  and  counter-pressure  on 
these  acting  through  the  acctabula.     Sonictimos  they  \xvi  in  excess  on 


376  LABOR. 

bones  which  are  heahhy,  but  possibly  smaller  than  usual,  and  the  result 
may  be  the  formation  of  certain  abnormalities  in  the  size  of  the  various 
pelvic  diameters.  At  other  times  they  operate  on  bones  Mhich  are 
softened  and  altered  in  texture  by  disease,  and  which  therefore  yield  to 
the  pressure  far  more  than  healthy  bones. 

The  two  diseases  which  chiefly  operate  in  causing  deformity  are  rjckets 
and  osteo-malaeia.  Into  the  essential  nature  and  symptomatology  of 
these  complaints  it  would  be  out  of  place  to  enter  here  :  it  may  suffice 
to  remind  the  reader  that  they  are  believed  to  be  pathologically  similar 
diseases,  with  the  important  practical  distinction  that  the  former  occurs 
in  early  life  before  the  bones  are  completely  ossified,  and  that  the  latter 
is  a  disease  of  adults  producing  softening  in  bones  that  have  been 
hardened  and  developed.  This  diiference  affords  a  ready  explanation  of 
the  generally  resulting  varieties  of  pelvic  deformity. 

Effects  of  Rickets. — Rickets  commences  very  early  in  life — sometimes, 
it  is  believed,  even  in  utero.  It  rarely  produces  softening  of  the  entire 
bones,  and  only  in  cases  of  very  great  severity  of  those  parts  of  the 
bones  that  have  been  already  ossified.  The  effects  of  the  disease  are 
principally  apparent  in  the  cartilaginous  portions  of  the  bones,  in  which 
osseous  deposit  has  not  yet  taken  place.  The  bones,  therefore,  are  not 
subject  to  uniform  change,  and  this  fact  has  an  important  influence  in 
determining  their  shape.  Rickety  children  also  have  imperfect  muscular 
development ;  they  do  not  run  about  in  the  same  way  as  other  children  ; 
they  are  often  continuously  in  the  recumbent  or  sitting  posture,  and 
thus  the  weight  of  the  trunk  is  brought  to  bear,  more  than  in  a  state  of 
health,  on  the  softened  bones.  For  the  same  reason,  counter-pressure 
through  the  acetabula  is  absent  or  comparatively  slight.  When,  how- 
ever, the  disease  occurs  for  the  fiisst  time  in  children  who  are  able  to  run 
about,  the  latter  comes  into  operation  and  modifies  the  amount  and  nature 
of  the  deformity.  It  is  to  be  observed  that  in  rickety  children  the  bones 
are  not  only  altered  in  form  from  pressure,  but  are  also  imperfectly  devel- 
oped ;  and  this  materially  modifies  the  deformity.  When  ossific  matter 
is  deposited,  the  bones  become  hard  and  cease  to  bend  under  external 
influences,  and  retain  for  ever  the  altered  shape  they  have  assumed. 

Efects  of  Osteo-malacia. — In  osteo-malacia,  on  the  contrary,  the  already 
hardened  bones  become  softened  uniformly  through  all  their  textures,  and 
thus  the  changes  which  are  impressed  upon  them  are  much  more  regular 
and  more  easily  predicated.  It  is,  however,  an  infinitely  less  common 
cause  of  pelvic  deformity  than  rickets,  as  is  evidenced  by  the  fiict  that 
in  the  Paris  Maternity,  in  a  period  of  sixteen  years,  402  cases  of  deform- 
ity due  to  rickets  occurred  to  1  due  to  osteo-malacia.^ 

Their  Varying  Frequency. — The  frequency  of  both  diseases  varies 
greatly  in  different  countries  and  under  different  circumstances.  Rickets 
is  much  more  common  amongst  the  poor  of  large  cities,  whose  children 
are  ill-fed,  badly  clothed,  kept  in  a  vitiated  atmosphere,  and  subjected 
to  unfavorable  hygienic  conditions.  Deformities  are  therefore  more  com- 
mon in  them  than  in  the  more  healthy  children  of  the  upper  classes  or 
of  the  rural  population.  The  higher  degrees  of  deformity,  necessitating 
the  Cfesarean  section  or  craniotomy,  are  in  this  country  of  extreme  rar- 

^  Stanesco,  Recherches  cliniques  sur  les  Relrecii^sements  du  Rasdn. 


DEFORMITIES  OF  THE  PELVIS.  377 

ity,  while  in  certain  districts  on  the  Continent  they  seem  to  be  so  fre- 
quent that  these  uhimate  resources  of  the  obstetric  art  have  to  be  con- 
stantly employed. 

Effects  of  Ossification  of  the  Pelvic  Articulations. — In  another  class  of 
cases  the  ordinary  shape  is  modified  by  weight  and  counter-pressure  ope- 
rating on  a  pelvis  in  which  one  or  more  of  the  articulations  is  ossified. 
In  this  way  we  have  produced  the  obliquely-ovate  pelvis  of  Naegele  or 
the  still  more  uncommon  tra/iisversely-contracted  pelvis  of  Hobert. 

Other  Causes  of  Pelvic  Deformity. — A  certain  number  of  deformed 
pelves  cannot  be  referred  to  a  modification  of  the  ordinary  development- 
al changes  of  the  bones.   Amongst  these  are  the  deformities  resulting  from  | 
spondylolisthesis,  or  downward  dislocation  of  the  lower  lumbar  verte-i 
brse ;   from  displacements  of  the  sacrum  caused  by  curvatures  of  the  | 
spinal  column,  producing  the  kyphotic  and  scoliotic  pelves  ;  or  from  dis- 
eases of  the  pelvic  bones  themselves,  such  as  tumors,  malignant  groMi:hs, 
and  the  like. 

Equally  Enlarged  Pelvis. — The  first  class  of  deformed  pelves  to  be 
considered  is  that  in  which  the  diameters  are  altered  from  the  usual 
standard  without  any  definite  distortion  of  the  bones ;  and  such  are 
often  mere  congenital  variations  in  size  for  which  no  definite  explana- 
tion can  be  given.  Of  this  class  is  the  pelvis  which  is  equally  enlarged^ 
in  all  its  diameters  (^pelvis  wquctbiliter  justo  major),  which  is  of  no  obstet- 
ric consequence,  except  inasmuch  as  it  may  lead  to  precipitate  labor,  and 
is  not  likely  to  be  diagnosed  during  life. 

Equally  Contracted  Pelvis. — The  corresponding  diminution  of  all  the 
pelvic  diameters  [pelvis  cequabiliter  justo  minor)  may  be  met  with  in<^ 
women  who  are  apparently  well  formed  in  every  respect  and  whose 
external  conformation  and  previous  history  gave  no  indication  of  the 
abnormality.  [^]  Sometimes  the  diminution  amounts  to  half  an  inch  or 
more,  and  it  can  readily  be  understood  that  such  a  lessening  in  the  capa- 
city of  the  pelvis  would  give  rise  to  serious  difficulty  in  labor.  Thus, 
in  3  cases  recorded  by  Naegele  a  fatal  result  followed — in  2  after  diffi- 
cult instrumental  delivery,  and  in  the  third  after  rupture  of  the  uterus. 
The  equally  lessened  pelvis,  however,  isof  great  rarity.  An  unusually 
small  pelvis  may  be  met  with  in  connection  with  general  small  size,  as 
in  dwarfs.  It  does  not  necessarily  follow,  because  a  woman  is  a  dwarf, 
that  the  pelvis  is  too  small  for  parturition.  On  the  contrary,  many  such 
women  have  borne  children  without  difficulty. 

The  Undeveloped  Pelvis. — In  some  cases  a  pelvis  retains  its  infantile 
characteristics  after  puberty  (Fig.  129).  The  normal  development  of  the 
pelvis  has  been  interfered  with,  possibly,  from  premature  ossification  of 

['  It  is  possible  for  a  lady  to  be  tali,  erect,  weigh  180  pounds,  and  lie  conspicnons  for 
her  line  apponrance,  wlien  she  has  a  jiiMo  minor  pelvis  of  very  small  interior  dimen- 
sions. I  examined  such  a  patient  some  years  ago,  and  not  only  had  she  the  smallest 
vagina  I  have  over  explored  in  a  well-grown  woman,  but  it  has  recenliy  ijeen  found  in 
lalioi-  that  iier  pelvis  woidd  not  admit  of  her  being  delivered  of  a  full-grown  living 
cliild.  In  fact,  it  is  doubtful  whether  she  could  be  delivered  of  one  alive  nnicli  lalcr 
than  the  seventh  month.  Married  twice  and  unimpregnated  for  years,  1  was  surprised 
at  lier  becoming  at  last  pregnant,  as  an  index  finger  filled  her  vagina  tightly.  After  a 
labor  of  three  days,  and  when  the  fictus  was  dead,  it  was  delivered  with  a  crushc;d  head 
after  long  and  powerful  trai-tion,  and  she  made  a  good  recovery.  Having  lai'ge  iiips, 
she  wa.s  under  an  imjiression  that  her  jielvis  was  of  corresponding  development. —  Kl).] 


378  LABOR. 


the  different  portions  of  the  innominate  bones  or  from  arrest  of  their 
growth  from  a  weakly  or  rachitic  constitution.  The  measurements  of 
these  pelves  are  not  always  below  the  normal  standard ;  they  may  con- 
tinue to  grow,  although  they  have  not  developed.  The  pro})ortionate 
measurements  of  the  various  diameters  ^vill  then  be  as  in  the  infant,  and 
the  antero-posterior  diameter  may  be  longer,  or  as  long,  as  the  transverse, 
the  ischia  comparatively  near  each  other,  and  the  pubic  arch  narrow. 
Such  a  form  of  pelvis  Mill  interfere  with  the  mechanism  (jf  delivery, 
and  unusual  difficulty  in  labor  will  be  experienced.   '  Difficulties  from  a 


Fig.  129. 


Adult  Pelvis  retaining  its  Infantile  Type. 


similar  cause  may  be  expected  in  very  young  girls.  Here,  however, 
there  is  reason  to  hope  that  as  age  advances  the  pelvis  Avill  develop  and 
subsequent  labors  be  more  easy. 

Masculine  or  Funnel-shaped  Pelvis. — The  mascid'ine  or  funnel-shaped 
pelvis  owes  its  name  to  its  approximation  to  the  type  of  the  male  pelvis. 
The  bones  are  thicker  and  stouter  than  usual,  the  conjugate  diameter  of 
the  brim  longer,  and  the  whole  cavity  rendered  deeper  and  narrower  at 
its  loM'cr  part  by  the  nearness  of  the  ischial  tuberosities.  It  is  generally 
met  with  in  strong,  muscular  women  following  laborious  occupations, 
and  Dr.  Barnes,  from  his  experience  in  the  Royal  Maternity  Charity, 
says  that  it  chiefly  occurs  in  weavers  in  the  neighborhood  of  Bethnal 
Green,  who  spend  most  of  their  time  in  the  sitting  posture.  ''  The 
cause  of  this  form  of  pelvis  seems  to  be  an  advanced  condition  of  ossifi- 
cation in  a  pelvis  which  would  otherwise  have  been  infantile,  brought 
about  by  the  development  of  unusual  nmscularity,  corresponding  to  the 
laborious  employment  of  the  individual."  The  difficulties  in  labor  will 
naturally  be  met  with  toward  the  outlet,  where  the  funnel  shape  of  the 
cavity  is  most  apparent. 

Contraction  of  Conjugate  Diameter  of  Brim. — Diminution  of  the 
antero-posterior  diameter  (^flattened  pelvin)  is  most  frequently  limited 
to  the  brim,  and  is  by  far  the  most  connnqn  variety  of  pelvic  deformity. 
In  its  slighter  degrees  it  is  not  necessarily  dependent  on  rickets,  although 


DEFORMITIES  OF  THE  PELVIS. 


379 


when  more  marked  it  almost  invariably  is  so.  When  unconnected  with 
rickets,  it  probably  can  be  traced  to  some  injurious  influence  before  the 
bones  have  ossified,  such  as  increased  pressure  of  the  trunk  from  carry- 
ing weights  in  early  childhood  and  the  like.  By  this  means  the  sacrum 
is  unduly  depressed  and  projects  forward,  so  as  to  slightly  narrow  the 
conjugate  diameter. 

Mode  of  Production  in  Rickets. — When  caused  by  rickets,  the  amount 
of  the  contraction  varies  greatly,  sometimes  being  very  slight,  sometimes 
sufficient  to  prevent  the  passage  of  the  child  altogether,  and  to  necessi- 
tate craniotomy  or  the  Csesarean  section.  The  sacrum,  softened  by  the 
disease,  is  pressed  vertically  downward  by  the  weight  of  the  body,  its  de- 
scent being  partially  resisted  by  the  already  ossified  portions  of  the  bone, 
so  that  the  I-esult  is  a  downward  and  forward  movement  of  the  promon- 
tory. The  upper  portion  of  the  sacral  cavity  is  thus  directed  more  back- 
ward ;  but,  as  the  apex  of  the  bone  is  drawn  forward  by  the  attachment 
of  the  perineal  muscles  to  the  coccyx  and  by  the  sacro-ischiatic  ligaments, 
a  sharp  curve  of  its  lower  part  in  a  forward  direction  is  established. 

Fig.  130. 


Scoliu-rachitic  Pelvis.    (From  a  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital.) 

Occasional  Increase  of  Transrerse  Diameter. — The  depression  of  the 
sacral  promontory  would  tend  to  produce  strong  traction,  through  the 
sacro-iliac  ligaments,  on  the  ]iosterior  end  of  the  sacro-cotyloid  beams,  and 
thus  induce  ex])ansion  of  the  iliac  bones  and  consequent  increase  of  the 
transverse  diameter  of  the  brim.  So  an  unusual  length  of  the  transverse 
diameter  is  very  oftvn  described  as  accom]ianying  this  deformity,  but  prob- 
ably it  is  not  so  often  a))par<!nt  as  might  other\^'is('  be  expected,  on  account 
of  the  im])erfect  development  of  the  bones  genei-ally  accompanying  rick- 
ets; and  Barnes'  says  that  in  th<!])arts  of  London  where  deformities  are 
most  rife  any  enlai'geiiient  of  the  transverse  diameter  is  exceedingly  rare. 

'  Ijcctiivfn  oil.  Olinl.  Operalionn,  p.  "80. 


380 


LABOR. 


The  f^colio-rachitic  and  Scoliotic  Pelvis. — Frequently  the  sacrum  is  not 
only  deiDressed,  but  displaced  more  or  less  to  one  side,  most  generally  to 
the  left,  thus  interfering  with  the  regular  shape  of  the  deformed  brim. 
This  is  often  the  result  of  a  lateral  Hexion  of  the  spinal  column  depend- 
ing on  the  rachitic  diathesis,  and  when  well  marked  is  known  as  the 
scolio-rachitic  pelviH  (Fig.  130),  in  ^vhich  one  side  of  the  pelvis,  that 
corresponding  to  the  direction  of  the  pelvic  curve,  is  asymmetrical  and 
contracted,  the  ilio-pectineal  line  being  sharply  curved  inward  about  the 
site  of  the  sacro-iliac  synchondrosis,  the  symphysis  pubis  being  displaced 
toward  the  opposite  side.  A  somewhat  similar  but  much  less  marked 
unilateral  asymmetry  may  exist  in  cases  of  scoliosis  [^]  unconnected  with 
rickets,  but  rarely  to  a  sufficient  degree  to  interfere  materially  with 
labor,  * 

Cavity  of  the  Pelvis  is  generally  not  Affected. — In  most  cases  of  this  kind 
the  cavity  of  the  pelvis  is  not  diminished  in  size,  and  is  often  even  more 
than  usually  wide.  The  constant  pressure  on  the  ischia  which  the  sitting 
posture  of  the  child  entails  tends  to  force  them  apart,  and  also  to  widen 

Fig.  131. 


Rickety  Pelvis    with  Backward  Depression  of  the  Symphysis  Pubis. 

the  pubic  arch.  Considerable  advantage  results  from  this  in  cases  in 
which  we  have  to  have  perform  obstetric  operations,  as  it  gives  plenty 
of  room  for  manipulation. 

Figure-of-Eight  Deformity. — In  a  few  exceptional  cases  the  narrowing 
of  the  conjugate  diameter  is  increased  by  a  backward  depression  of  the 
symphysis  pubis,  which  gives  the  pelvic  brim  a  sort  of  figure-of-eight 
shape  (Fig.  131).     The  most  reasonable  explanation  of  this  peculiarity 

[^Although  hunchbacks  frequently  have  well-formed  pelves,  it  is  not  uncommon  to 
find  a  deformed  spine  associated  with  an  asymmetrical  pelvis  or  even  a  much  contracted 
one.  Spinal  distortion  from  caries,  especially  in  the  lumbar  region,  is  thus  associated, 
and  tlie  pelvic  deformity  will  be  increased  if  there  has  been  coxalgia,  either  double  or 
single,  or  if  from  any  cause  one  leg  should  be  shorter  than  the  other.  In  the  records 
of  the  Porro  operation  we  find  under  "the  cause  of  difficulty,"  " pseudo-osieo-malacia," 
"  liiriibn-chr.'icil  h/pliofiix"  "  kyplin-scolio.'iis,"  etc.  Pffeiidn-o.'iteo-nnilnci((  is  the  result  of 
rickets  in  a  walking  child,  the  form  of  pelvis  being  changed  mechanically,  as  in  osteo- 
malacia. Liimbo-dorsal  /.ypliosis  may  or  may  not  give  rise  to  tlie  kyphotic  pelvis,  as 
much  will  depend  upon  the  extent  of  vertebral  caries.  Scoliosig  is  apt  to  result  from 
rickets,  and  may  be  associated  with  /ojrfos/.s. 

Scoliof;is,  from  Gim'/./oc,  crooked — a  distortion  of  the  spine  to  one  side. 

Lordodg,  from  ?iopJof,  curved — api)lied  particularly  to  the  forward  bending  of  the 
spine. 

Kyphosis,  from  i;vipuaic,  gibbous,  arched,  or  vaulted — a  hump  or  backward  curvature 
of  the  spine. — Ed.] 


DEFORMITIES  OF  THE  PELVIS. 


381 


seems  to  be  that  it  is  the  resuh  of  the  muscular  contraction  of  the  recti 
muscles  at  their  point  of  attachment,  when  the  centre  of  gravity  of  the 
body  is  thrown  backward  on  account  of  the  projection  of  the  sacral  prom- 
ontory. Sometimes,  also,  the  antero-posterior  diameter  of  the  cavity  is 
unusually  lessened  by  the  disappearance  of  the  vertical  curvature  of 
the  sacrum,  which,  instead  of  forming  a  distinct  cavity,  is  nearly  flat 
(Fig.  132). 

Spondylolisthesis. — In  a  few  rare  cases,  to  which  attention  was  first 
called  in  1853  by  Kilian  of  Bonn,  a  very  formidable  narrowing  of  the 
conjugate  diameter  of  the  pelvic  brim  is  produced  by  a  downward  dis- 
placement of  the  fourth  and  fifth  lumbar  vertebrae,  which  become  dislo- 
cated forward,  or,  if  not  actually  dislocated,  at  least  separated  from  their 
several  articulations  to  a  sufficient  extent  to  encroach  very  seriously  on 
the  dimensions  of  the  pelvic  inlet.  This  condition  is  known  as  sjjondyl- 
■olisthesis  [^^  (Fig.  133). 


Fig.  132. 


Fig.  133. 


Flatness  of  Sacrum,  with  Narrowing  of 
Pelvic  Cavity. 


Pelvis  Deformed  by  Spondylolisthesis. 
(After  Kilian.)  .>!i 


The  effect  of  this  is  sufficiently  obvious,  for  the  projection  of  the 
lumbar  vertebrae  prevents  the  passage  of  the  child.  To  such  an  extent 
is  obstruction  thus  produced  that  in  the  majority  of  the  recorded  cases 
the  Csesarean  section  was  necessary.  The  true  conjugate  diameter,  that 
between  the  promontory  of  the  sacrum  and  the  symphysis  pubis,  is 
increased  rather  than  diminished ;  but,  for  all  practical  purposes,  the 
condition  is  similar  to  extreme  narrowing  of  the  conjugate  from  rick- 
ets, for  the  bodies  of  the  displaced  vertebrae  project  into  and  obstruct  the 
jK'lvic  brim. 

The  cause  of  this  deformity  seems  to  be  different  in  different  cases. 
In  some  it  seems  to  have  been  congenital,  and  in  others  to  have  depended 
on  some  antecedent  disease  of  the  bones,  such  as  tuberculosis  or  scrofula, 
producing  inflammation  and  softening  of  tlu;  coiuiection  betwec^n  the  last 
luiiil)ar  v(;rtebra  :uid  tlu;  sacrum,  tluis  ])ern)itting  downwai'd  displace- 
iiiciit  of  the  bones.  Lambl  believed  that  it  generally  followed  sj)ina 
['  From  airovM.nr,  the  verteljni,  and  n7j.adT/mr^  a  slipping  or  sliding-.  —  ICi).] 


382 


LABOR. 


bifida  which  had  become  partially  cured,  but  which  liad  })r(jduccd 
deformity  of  the  vertebra;  and  favored  their  dislocation.  Brodhurst/ 
on  the  other  hand,  thinks  that  it  most  probably  depends  on  rachitic 
inflammation  and  softening  of  the  osseous  and  ligamentous  structures, 
and  that  it  is  not  a  dislocation  in  the  strict  sense  of  the  word.  This  con- 
dition has  recently  been  made  the  subject  of  special  study  by  Dr.  Franz 
Neugebauer,^  who  believes  that  the  forward  displacement  is  never  the 
result  of  antecedent  disease  of  the  bones,  but  depends  either  on  congeni- 
tal want  of  development  of  the  vertebral  arches  or  on  traumatism,  such 
as  fracture  of  the  articular  processes,  which  allows  the  weight  of  the 
trunk  to  displace  the  body  of  the  last  lumbar  vertebra  forward,  either 
partially  or  entirely. 

[We  are  indebted  to  Kilian  of  Germany  for  the  first  careful  investi- 
gation of  the  true  character  of  sjjondylolisthetic  deformity,  although  the 

credit  of  initial  mention  is  due  to 
Fig.  134.  Eokitansky  of  Austria,  who  wrote 

t,4  M,M*$yCS-f^  in  1839,  antedating  the  monograph 
of  the  former  (1853)  by  fourteen 
years.  No  special  mention  is  made 
of  this  peculiar  lordosis  by  Eoki- 
tansky in  his  Manual  of  Faihohr/- 
ical  Anatomy  in  1844,  but  in  Jiis 
Lehrbuch  (1855)  it  is  given,  with 
due  credit  to  Kilian.  During  the 
thirty  years  that  have  passed  since 
Kilian  prepared  his  paper  from  ob- 
servations made  upon  three  pelves 
which  had  been  obtained  from  sub- 
jects in  whom  the  Csesarean  section 
had  proved  fatal,  one  of  them  after 
a  second  operation,  there  have  ap- 
peared numerous  monographs  and 
descriptions  of  cases,  much  the  most 
valuable  and  extensive  of  which  are 
those  by  Dr.  Franz  Ludwig  Neuge- 
bauer  of  Warsaw  and  Dr.  A.  Swedelin  of  St.  Petersburg,  the  latter  of 
whom  furnishes  the  bibliography  of  the  subject.  These  valuable  papers 
cover  153  and  40  pages,  "respectively,  of  i\\e  Archiv  fur  Gipuvhologie, 
Berlin,  the  former  having  87  illustrations  and  the  latter  7,  and  may  be 
found  in  vols,  xix.,  xx.,  xxi.,  and  xxii.,  for  1882-84. 

The  cause  or  causes  of  spondylolisthesis  have  not  as  yet  been  very 
satisfactorily  determined.  The  disease  in  some  of  its  features  would 
appear  to  be  a  form  of  local  malacosteon  or  of  osieith  deformans,  differ- 
ing from  the  former  in  the  flict  that  it  may  occur  without  pain,  that  the 
general  health  may  not  be  impaired,  and  that  the  subjects  may  be  nulli- 
parous ;  which  last  is  exceedingly  rare  in  malacosteon.  In  the  lordosis 
of  ordinary  malacosteon  there  is  no  sliding  of  the  last  lumbar  vertebra, 
or  this  peculiar  deformity  would  be  much  less  infrequent.     As  it  is^ 

^  Ohd.  Trans.,  vol.  vi.  p.  97. 

2  Contribution  a  la  Pathogenie  du  Baf^dn  Vide  pur  le  GliKsement  vertebral,  Paris,  1884. 


[Spondylolifetbesis.    (After  Neugebauer.)] 


DEFORMITIES  OF  THE  PELVIS.  383 

after  an  extended  search  by  a  number  of  writers,  we  are  limited  to  the 
study  of  17  pelves  and  25  clinical  cases:  the  photographic  process  has 
also  made  us  familiar  with  the  contour  of  body  produced  by  the  disease. 
The  effect  of  the  spinal  slipping  and  anterior  curvature  of  the  loins  is  to 
shorten  the  trunk  of  the  woman,  cause  a  pouch-like  protrusion  of  her 
abdomen,  and  elevate  and  widen  the  hips.  As  the  pelvis  is  not  col- 
lapsed, there  is  no  alteration  in  the  pubes  or  hip-joints,  and  as  many  of 
the  subjects  are  robust,  their  change  of  form  is  quite  perceptible  even  in 
full  dress.  The  only  true  test  of  the  condition  is  the  discovery  per  vagi- 
nam  of  the  overhanging  fifth  lumbar  vertebra,  with  which  may  also  be 
felt  the  pulsation  of  the  primitive  iliacs,  and  in  extreme  cases  even  the 
bifurcation  of  the  aorta.  The  shortening  of  the  abdominal  cavity  forces 
the  pregnant  uterus  into  an  extreme  anterior  obliquity,  which,  by  inter- 
fering with  the  line  of  its  expulsive  action,  adds  to  the  difficulty  pro- 
duced by  the  narrowing  of  the  conjugate  diameter. 

We  have  a  special  interest  in  the  study  of  this  deforming  malady 
from  the  fact  that  one  of  the  cases  on  record  occurred  in  San  Francisco 
under  the  care  of  Prof.  James  Blake  of  Toland  Medical  College,  and 
was  reported  by  him  in  the  Pacific  3Ied.  and  Sioy.  Journal  of  Feb.,  1867. 
The  subject  of  this  disease  was  married  at  15  years  of  age,  at  which 
time  she  weighed  101  pounds,  but  increased  to  199  pounds  by  the  time 
her  first  child  was  born.  Her  first  and  second  labors  were  tedious,  but 
the  children  were  born  alive ;  she  aborted  of  another  foetus  at  four 
months,  and  later  was  delivered  at  maturity  of  four  others,  all  dead,  the 
conjugate  space  in  the  seventh  labor  being  computed  at  3^  inches.  This 
labor  was  so  difficult  that  it  was  decided,  in  the  event  of  another  preg- 
nancy, to  bring  on  labor  prematurely.  She  became  pregnant  for  the 
eighth  time  at  the  age  of  26,  when  she  weighed  220  pounds.  Labor 
was  induced  in  the  seventh  month,  but  the  foetus  was  lost,  as  it  weighed 
nearly  six  pounds  and  the  lumbo-pubic  space  was  reduced  to  3  inches. 
This  woman  is  said  to  have  undergone  the  change  in  her  vertebrse  with- 
out pain  or  sign  of  ill-health,  and  to  have  retained  a  remarkable  activity 
for  her  weight.  After  her  eighth  delivery  she  was  up  in  six  days,  and 
down  stairs  in  ten.  The  history  of  this  case  would  indicate  that  the 
deforming  process  must  have  been  slowly  progressing  during  more  than 
ten  years. 

In  contrast  with  this  painless  case  in  a  multipara  we  have  the  oppo- 
site in  a  nullipara,  reported  by  Dr.  Olshausen  of  Halle.  The  disease 
commenced  in  his  patient  when  a  girl  of  18  with  severe  pains  in  the 
sacrum  and  hips,  as  in  malacosteon.  She  had  not  had  rickets  in  child- 
hood, had  enjoyed  good  health  up  this  time,  and  was  quite  straight.  As 
her  disease  progressed  she  found  on  awaking  one  morning  that  slie  could 
not  straighten  her  spiue,  aud  was  forced  to  walk  Avith  her  body  bent 
foi'ward.  She  was  put  under  medical  treatment  at  tlie  surgical  clini(^ ; 
had  no  fever,  and  in  time  ceased  to  suffer,  and  was  discharged.  Becom- 
ing pregnant  at  the  age  of  24,  Dr.  Olshausen  delivered  her  in  1863  by 
the  Cesarean  section  :  the  child  lived,  but  she  was  lost  on  the  fourth 
(lay  by  peritonitis.  Tiie  lunibo-pul)i(;  diameter  was  found  to  measure  3 
inches,  and  the  line  of  the  conjugate  struck  the  lower  margin  of  the  third 
lumbar  vertebi'a. 


384  LABOR. 

Spondylolisthesis  must  not  be  confounded  with  that  form  of  lumbar 
lordo^k  in  which  the  fifth  vertebra  retains  its  proper  articulation  with 
the  top  of  the  sacrum,  or  with  that  produced  by  lumbo-sacral  caries. 
In  true  spondylolisthetic  deformity  the  superior  strait  is  not  distorted, 
but  is  encroached  upon  from  above  by  the  sagging  down  of  the  lumbar 
vertebrae,  and  particularly  by  the  slii^ping  forward  of  the  entire  body  of 
the  fifth.  A  vertical  section  of  the  himbo-sacral  spine  will  show  that 
the  displaced  vertebra  has  in  some  cases  been  thinned,  and  that  in  others 
the  top  of  the  sacrum  has  been  compressed  and  new  bone  thrown  out  to 
give  additional  support  to  the  dislodged  vertebra.  To  accomplish  this 
without  paralysis,  there  must  necessarily  "be  some  softening  of  bone  and 
cartilage,  with  relaxation  of  ligaments  and  a  gradual  giving  way,  espe- 
cially at  the  sacro-vertebral  articulation,  M-ith  an  enlargement  of  the 
spinal  canal  in  the  slipping  portion  to  avoid  pinching  the  sjjinal  nerve. 
Certainly,  the  clinical  history  of  some  of  the  cases  cannot  be  explained, 
except  under  the  belief  that  there  has  been  some  antecedent  bone  disease 
affecting  at  least  the  articulating  processes.  Prof.  Blake  attributed  the 
deformity  in  his  case  to  a  dislocation  produced  by  a  rapid  increase  in 
weight ;  but  hundreds  of  women  are  subjected  to  the  same  cause  and 
remain  straight ;  and,  besides,  his  patient  must  have  had  a  very  gradual 
dislocation.  The  theory  of  fracture  of  the  articular  processes  is  not  at 
all  satisfactory,  as  the  gravity  of  the  symptoms  is  not  indicative  of  such 
an  accident  having  occurred  ;  neither  is  that  of  a  congenital  defect  in  the 
said  processes,  although  this  may  account  for  some  of  the  cases,  espe- 
cially if  we  admit  that  the  defective  articulations  may  become  insufficient 
to  support  the  weight  of  the  trunk  by  reason  of  a  w^eakening  produced 
by  disease. — Ed.] 

Sponclylolizema. — A  somewhat  analogous  deformity  has  been  described 
by  Hergott^  under  the  name  of  sponclylolizema.  In  this  the  bodies  of 
the  lower  lumbar  vertebrae  having  been  destroyed  by  caries,  the  upper 
lumbar  vertebrae  sink  downward  and  forward,  so  as  to  obstruct  the  pel- 
vic inlet  and  prevent  the  engagement  of  the  foetus.  It  thus  differs  from 
spondylolisthesis,  in  which  there  is  dislocation,  but  not  destruction,  of 
the  bodies  of  the  lower  lumbar  vertebrae. 

Narrowing  of  the  Oblique  Diameter. — The  most  marked  examples  of 
narrowing  of  both  oblique  diameters  depend  on  osteo-malacia.  In  this 
disease,  as  has  already  been  remarked,  ^\e  bones  are  uniformly  softened, 
and  the  alterations  in  form  are  further  influenced  by  the  fact  that  the 
disease  commences  after  union  of  the  sejjarate  portions  of  the  ossa  inno- 
minata  has  been  completely  effected.  The  amount  of  deformity  in  the 
worst  cases  is  very  great,  and  frequently  renders  delivery  impossible 
without  the  Csesarean  section.  Sometimes  the  softening  of  the  bones 
proves  of  service  in  delivery,  by  admitting  of  the  dilatation  of  the  con- 
tracted pelvic  diameter  by  the  pressure  of  the  presenting  part  or  even 
by  the  hand.  Some  curious  cases  are  on  record  in  which  tlie  deformity 
was  so  great  as  to  apparently  require  the  Caesarean  section,  but  in 
which  the  softened  bones  eventually  yielded  suffiiciently  to  render  this 
unnecessary. 

3Iode  of   Production  in    Osteo-malacia. — The  weight  of  the    body 

^  Arch,  de  Tocologic,  1877. 


DEFORMITIES  OF  THE  PELVIS. 


385 


depresses  the  sacrum  in  a  vertical  direction,  and  at  the  same  time  com- 
presses its  component  parts  together,  so  as  to  approximate  the  base  and 
apex  of  the  bone,  and  narrow  the  conjugate  diameter  of  the  brim  bj 


Fig.  135. 


Osteo-malacic  Pelvis. [i] 

causing  the  promontory  to  encroach  upon  it.  The  most  characteristic 
changes  are  produced  by  the  pushing  inward  of  the  walls  of  the  pelvis 
at  the  cotyloid  cavities  in  consequence  of  pressure  exerted  at  these  points 
through  the  femora.  The  effect  of  this  is  to  diminish  both  oblique 
diameters,  giving  the  brim  somewhat  the  shape  of  a  trefoil  or  an  ace  of 
clubs.  The  sides  of  the  pubes  are  at  the  same  time  approximated,  and 
may  become  almost  parallel,  and  the  true  conjugate  may  be  even  length- 
ened (Fig.  135).  The  tuberosities  of  the  ischia  are  also  compressed 
together  with  the  rest  of  the  lateral  pelvic  wall,  so  that  the  outlet  is 
greatly  deformed  as  well  as  the  brim  (Fig.  136). 

Fig.  136. 


Extreme  Degree  of  Osteo-inulacic  DeI'Drmity. 

[Odeo-malacia  not  an  American  Disease. — In  not  one  of  the  134 
Cjcsarean  cases  of  the  United  States  was  the  operation  jierformed  for 
this  form  of  deformity.     Tn  a  few  instances  tlie  malady  has  been  found 

['  This  form  is  known  as  rostrate  or  beaked. — Ed.] 
26 


386  LABOR. 

in  foreigners,  and  the  forceps  or  craniotomy  used    in  their  delivery. 

Many  obstetricians  of  large  experience  have  never  seen  a  case,  and  I  do 

not  know  of  an  instance  of  extreme  rostration  of  the  pelvis  having  been 

met  with  in  this  country. — Ed.] 

ObUquely-contracted  Pelvis. — That  form  of  deformity  in  Mhich  one 

oblique  diameter  only  is  lessened  has   received   considerable  attention, 

from  having  been  made  the  subject  of 
Fig.  137.  special  study  by  Naegele,  and  is  gener- 

ally known  as  the  obliquely-contracted 
•pelvis  (Fig.  137).  It  is  a  condition 
that  is  very  rarely  met  with,  although 
it  is  interesting  from  an  obstetric  point 
of  vicAV,  as  throwing  considerable  light 
on  the  mode  in  which  the  natural  de- 
velopment of  the  pelvis  is  effected.  It 
is  difficult  to  diagnose,  inasmuch  as 
there  is  no  apparent  external  deform- 
ity, and  probably  it  has  never,  in  fact, 
been  detected  before  deliverv.     It  has 

Obliquelv-contracted  Pelvis.  •  •     n  -\  \  t  •, 

(After  Duncan.)  a  Very  scrious  mtluence  on  labor:  JLitz- 

mann  found  that  out  of  28  cases  of  this 

deformity,  22  died  in  their  labors  and  5  more  in  subsequent  deliveries. 

The  prognosis,  therefore,  is  very  formidable,  and  renders  a  knowledge 

of  this  distortion,  rare  though  it  be,  of  importance. 

Its  essential  characteristic  is  flattening  and  want  of  development  of 
one  side  of  the  pelvis,  associated  with  anchylosis  of  the  corresponding 
sacro-iliac  synchondrosis.  The  latter  is  probably  always  present,  and  it 
seems  to  be  most  generally  a  congenital  malformation.  The  lateral  half 
of  the  sacrum  on  the  same  side,  and  the  entire  innominate  bone,  are  much 
atrophied.  The  promontory  of  the  sacrum  is  directed  toward  the  diseased 
side,  and  the  symphysis  pubis  is  pushed  over  toward  the  healthy  side. 

The  main  agent  in  the  production  of  this  deformity  is  the  absence  of 
the  sacro-iliac  joint,  which  prevents  the  proper  lateral  expansion  of  the 
pelvic  brim  on  that  side,  and  allows  the  counter-pressure,  through  the 
femur,  to  push  in  the  atrophied  os  innominatum  to  a  much'  greater 
extent  than  usual.  The  chief  diminution  in  the  length  of  the  pelvic 
diameter  is  between  the  ilio-pectineal  eminence  of  the  affected  side  and 
the  healthy  sacro-iliac  joint,  while  the  oblique  diameter  between  the 
anchylosed  joint  and  the  healthy  os  innominatum  is  of  normal  length. 

[Another  form  of  obliquely-contracted  pelvis  is  the  result  of  coxalgic 
atrophy  of  one  ilium,  produced  by  hip  disease  in  early  childhood,  the 
side  of  the  pelvis  being  stunted  in  growth,  as  well  as  the  whole  extrem- 
ity attached  to  it.  Two  Csesarean  operations  have  been  performed  in 
the  United  States  in  cases  having  this  form  of  deformity. — Ed.] 

Narrotving  of  the  Transverse  Diameter. — Transverse  contraction  of 
the  pelvic  brim  is  very  much  less  common  than  narrowing  of  the  con- 
jugate diameter.  It  most  frequently  depends  on  backward  curvature 
of  the  lower  parts  of  the  spinal  column  in  consequence  of  disease  of  the 
vertebrae.  This  form  of  deformed  pelvis  is  generally  known  as  the 
kyphotic  (Fig.  138).     The  effect  of  the  spinal  curvature  is  to  drag  the 


DEFORMITIES  OF  THE  PELVIS. 


387 


promontory  of  the  sacrum  backward,  so  that  it  is  high  up  and  out  of 
reach.  By  this  means  the  antero-posterior  diameter  of  the  brim  is 
increased,  while  the  transverse  is  lessened ;  the  relative  proportion 
between  the  two  is  thus  reversed.     While  the  upper  portion  of  the 

Fig.  138. 


Kyphotic  Pelvis. 
(From  a  specimen  in  the  Museum  of  St.  Bartholomew's  Hospital.) 

sacrum  is  displaced  backward,  its  lower  end  is  projected  forward,  so 
that  the  antero-posterior  diameters  of  the  cavity  and  outlet  are  consider- 
ably diminished.  The  ischial  tuberosities  are  also  nearer  to  each  other, 
and  the  pubic  arch  is  narrowed.  Obstruction  to  delivery  will  be  chiefly 
met  with  at  the  lower  parts  and  outlet  of  the  pelvic  cavity,  for,  although 
the  transverse  diameter  of  the  brim  is  narrowed,  there  is  generally  suf- 
ficient space  for  the  passage  of  the  head. 

Robertas  Pelvis. — Another  form  of  transversely-contracted  pelvis  is 
known  as  Robert's  pelvis  (Fig.  139),  having  been  first  discovered  by 

Robert  of  Coblentz.  It  is  in  fact  a 
double  obliquely-contracted  pelvis,  de- 
pending on  anchylosis  of  both  sacro- 
iliac joints,  and  consequent  defective 
development  of  the  innominate  bones. 
The  shape  of  the  pelvic  brim  is  mark- 
edly oblong,  and  the  sides  of  the  pel- 
vis are  more  or  less  parallel  with  each 
other.  The  outlet  is  also  much  con- 
tracted transversely.  Tlie  amount  of 
()l)stru<'tion  is  very  great,  so  that,  ac- 
cording to  Schroedcr,  out  of  7  well- 
anthenticated  cases  the  Csesarean  s(!('- 
pcivi.s.   (Afur  I'uiK'un.)  tiou  vvas  rcqnired  in  6. 


Fig 


388 


LABOR. 


Fig.  140. 


[The  Porro-Csesarean  operation  has  only  been  called  for  in  one  instance, 
by  reason  of  this  rare  condition.  Prof.  Josef  Spilth  of  Vienna  operated 
with  success  to  mother  and  child  on  March  7,  1883.  The  C.  v.  measured 
3|-  inches,  and  the  bis-ischiatic  only  1  inch. — Ed.] 

Deformity  from  Old-standing  Hip-joini  Disease. — Another  cause  of 
transverse  deformity  occasionally  met  with  is  luxation  of  the  head  of 
the  femur,  depending  on  old-standing  joint-disease.  The  head  of  the 
femur  in  this  case  presses  on  the  innominate  bone  at  the  site  of  disloca- 
tion, and  the  result  is  that  the  iliac  fossa  on  the  affected  side,  or  both  if 
the  accident  happens  on  both  sides,  is  pushed  inA^'ard,  the  transverse 
diameter  of  the  brim  being  lessened.  The  tuberosity  of  the  ischium  is, 
however,  projected  outward,  so  that  the  outlet  of  the  pelvis  is  increased 
rather  than  diminished. 

Deformity  from  Tumors,  Fractures,  etc. — Obstruction  of  the  pelvic 
cavitv  from  exostoses  or  other  forms  of  tumors  e-rowinp;  from  the  bones 

is  of  great  rarity  (Fig.  140).  It  may, 
however,  produce  very  serious  dys- 
tocia. Several  curious  examples  are 
collected  in  Mr.  Wood's  article  on 
the  pelvis,  in  some  of  which  the  ob- 
struction was  so  great  as  to  necessi- 


tate the  Cesarean  section.  [^]  Some 
of  these  growths  were  true  exostoses, 
and,  according  to  Stadtfeldt,^  these 
are  commonly  found  in  pelves  that 
are  otherwise  contracted ;  others,  os- 
teo-sarcomatous  tumors  attached  to 
the  pelvic  bones,  most  generally  the 
upper  part  of  the  sacrum  ;  and  others 
were  malignant.  In  some  cases  spicu- 
Ise  of  bone  have  developed  about  the 
linea  ilio-pectinea  or  other  parts  of 
the  pelvis,  which  may  not  be  sufficient 
to  produce  obstruction,  but  which 
may  injure  the  uterus,  or  even  the 
foetal  head,  when  they  are  pressed  upon  them.  Irregular  projections 
may  also  arise  from  the  callus  of  old  fractures  of  the  pelvic  bones.  All 
such  cases  defy  classification,  and  differ  so  greatly  in  their  extent  and  in 
their  effect  on  labor  that  no  rules  can  be  laid  dow  n  for  them,  and  each 
must  be  treated  on  its  own  merits. 

Effects  of  Contracted  Pelvis  in  Labor. — The  effects  of  pelvic  contrac- 
tions on  labor  vary,  of  course,  greatly  with  the  amount  and  nature  of 
the  deformity ;  but  they  must  always  give  rise  to  anxiety,  and  in  the 
graver  degrees  they  produce  the  most  serious  difficulties  we  have  to  con- 
tend with  in  the  whole  range  of  obstetrics. 

Nature  of  Uterine  Action  in  Pelvic  Deformity. — In  the  lesser  degrees, 

\}  Ten  Csesarean  operations  in  the  United  States  saved  four  of  the  cases  and  five 
children.  One  fatal  case  had  been  in  labor  two  weeks ;  one,  four  days ;  two,  three 
days;    and  one,  two  days. — Ed.] 

^  Obstetrical  Journal,  July,  1879. 


Bony  Growth  from  Sacrum  obstructing  the 
Pelvic  Cavity. 


DEFORMITIES  OF  THE  PELVIS.  389 

in  which  the  proportion  between  the  presenting  part  and  the  pelvis  is 
only  slightly  altered,  we  may  observe  little  abnormal  beyond  a  greater 
intensity  of  the  pains  and  some  protraction  of  the  labor.  It  is  gener- 
ally observed  that  the  uterine  contractions  are  strong  and  forcible  in 
cases  of  this  kind,  probably  because  of  the  increased  resistance  they  have 
to  contend  against ;  and  this  is  obviously  a  desirable  and  conservative 
occurrence,  which  may  of  itself  suffice  to  overcome  the  difficulty.  The 
first  stage,  however,  is  not  unfrequently  prolonged  and  the  pains  are 
ineffective,  for  the  head  does  not  readily  engage  in  the  brim,  the  uterus  \ 
is  more  mobile  than  in  ordinary  labors,  and  it  probably  acts  at  a  dis-  ■ 
advantage. 

Risk  to  the  Mother. — In  the  more  serious  cases  the  mother  is  subjected  J*<,^  iv 
to  many  risks,  directly  proportionate  to  the  amount  of  obstruction  and 
the  length  of  the  labor.  The  long-continued  and  excessive  uterine  action  '"  !-U-U 
produced  by  the  vain  endeavors  to  push  the  child  through  the  contracted 
pelvic  canal,  the  more  or  less  prolonged  contusion  and  injury  to  which 
the  maternal  soft  parts  are  necessarily  subjected  (not  unfrequently  end- 
ing in  inflammation  and  sloughing  with  all  its  attendant  dangers),  and 
the  direct  injury  which  may  be  inflicted  by  the  measures  we  are  com- 
pelled to  adopt  for  aiding  delivery  (such  as  the  forceps,  turning,  crani- 
otomy, or  Csesarean  section), — all  tend  to  make  the  prognosis  a  matter 
of  grave  anxiety. 

Rish  to  the  Child. — Nor  are  the  dangers  less  to  the  child,  and  a  very  .}}jJjl 
large  proportion  of  stillbirths  will  always  be  met  with.  The  infantile 
mortality  may  be  traced  to  a  variety  of  causes,  the  most  important  being 
the  protraction  of  the  labor  and  the  continuous  pressure  to  which  the 
presenting  part  is  subjected.  For  this  reason,  even  in  cases  in  which  the 
contraction  is  so  slight  that  the  labor  is  terminated  by  the  natural  powers, 
it  has  been  estimated  that  1  out  of  every  5  children  is  stillborn ;  and  as 
the  deformity  increases  in  amount,  so,  of  course,  does  the  prognosis  to 
the  child  become  more  unfavorable. 

Frequent  Ooeurrence  of  Prolapse  of  the  Cord. — Prolapse  of  the  um- 
bilical cord  is  of  very  frequent  occurrence  in  cases  of  pelvic  deformity, 
the  tendency  to  this  accident  being  traceable  to  the  fact  of  the  head  not 
entering  and  occupying  the  upper  strait  of  the  pelvis  as  in  ordinary 
labors,  and  thus  leaving  a  space  through  which  the  cord  may  descend,  i 
So  frequently  is  this  complication  met  with  in  pelvic  deformity  that 
Stanesco  ^  found  it  had  happened  as  often  as  59  times  in  414  labors  ;  and 
when  the  dangers  of  prolapsed  funis  are  added  to  those  of  protracted 
labors,  it  is  hardly  a  matter  of  surprise  that  the  occurrence  should,  under 
such  circumstances,  almost  always  prove  fatal  to  the  child. 

Injury  to  ChiMs  Head. — The  head  of  the  child  is  also  liable  to  injury 
of  a  more  or  less  grave  character  from  the  compression  to  ^vhich  it  is , 
subjected,  especially  by  the  promontory  of  the  sacrum.  Independently  I 
of  the  transient  effects  of  undue  pressure  (tem])orary  alteration  of  the 
shape  of  tfie  bones  and  bi'uising  of  the  s(;alp),  there  is  often  met  witli  a 
nior(!  serious  depr(!ssion  of  the  bones  of  the  skidl  produced  l)y  the  sacral 
pi"(»riiontory.  Tiiis  is  most  marked  in  (•as(is  in  which  the  head  has  been 
forcibly  dragged  past  the  projecting  bone  by  the  forcej)s  or  after  turning. 

•  Op.  riL,  p.  94. 


390  LABOR. 

Tlie  amount  of  depression  varies  with  the  degree  of  contraction ;  but 
sometimes,  were  it  not  for  the  yielding  of  the  bones  of  the  foetal  skull 
in  this  way,  delivery,  without  lessening  the  size  of  the  head  by  perfora- 
tion, would  be  impossible.  Such  depressions  are  found  at  the  spot 
immediately  opposite  the  promontory,  generally  at  the  side  of  the  skull 
near  the  junction  of  the  frontal  and  parietal  bones.  Sometimes  there  is 
a  slight  permanent  mark,  but  more  often  the  depression  disappears  in  a 
few  days.  The  prognosis  to  the  child  is,  however,  grave  when  the  con- 
traction has  been  sufficient  to  indent  the  skull,  for  it  has  been  found  that 
50  per  cent,  of  the  children  thus  marked  died  either  immediately  or 
shortly  after  labor.' 

Course  of  Labor. — The  means  which  nature  takes  to  overcome  these 
difficulties  are  well  worthy  of  study,  and  there  are  certain  peculiarities  in 
the  mechanism  of  delivery,  when  pelvic  deformities  exist,  which  it  is  of 
importance  to  understand,  as  they  guide  us  in  determining  the  proper 
treatment  to  ado23t. 

Frequency  of  Malpresentation. — Malpresentations  of  the  foetus  are  of 
much  more  frequent  occurrence  than  in  ordinary  labors — partly  because 
the  head  does  not  engage  readily  in  the  brim,  but,  remaining  free  above 
it,  is  apt  to  be  pushed  away  by  the  uterine  contractions ;  and  partly 
because  of  the  frequent  alteration  of  the  axis  of  the  uterine  tumor.  The 
pendulous  condition  of  the  abdomen  in  cases  of  pelvic  deformity  is  often 
very  obvious,  so  that  the  fundus  is  sometimes  almost  in  a  line  with  the 
cervix,  and  thus  transverse  or  other  abnormal  positions  are  very  fre- 
quently met  with.  It  is  to  be  noted,  however,  that  w^e  cannot  regard 
breech  presentations  as  so  unfavorable  as  in  ordinary  labors,  for  the  pres- 
sure from  the  contracted  pelvis  is  less  likely  to  be  injurious  when  applied 
to  the  body  than  to  the  head  of  the  child  ;  and,  indeed,  as  we  shall  pres- 
ently see,  the  artificial  production  of  these  presentations  is  often  advisable 
as  a  matter  of  choice. 

Meclicmism  of  Delivery  in  Head  Presentations. — The  mode  in  which 
the  head  passes  naturally  through  a  contracted  pelvis  is  in  some  respects 
different  from  the  ordinary  mechanism  of  delivery  in  head  presenta- 
tions, and  has  been  carefully  worked  out  by  Spiegelberg  and  other  Ger- 
man obstetricians. 

The  means  which  nature  adopts  to  overcome  the  difficulty  are  differ- 
ent in  cases  in  which  there  is  a  marked  narrowing  of  the  conjugate 
diameter  of  the  brim,  and  in  those  in  wliicli  there  is  a  generally-con- 
tracted pelvis. 

In  Contra,cted  Brim. — In  the  former  and  more  common  deformity  the 
head  lies  at  the  brim  with  its  long  occipito-frontal  diameter  in  the  trans- 
verse diameter  of  the  pelvis,  and,  as  both  parietal  bones  cannot  entei 
the  contracted  brim,  it  lies  with  one  parietal  bone  on  a  much  lower  level 
than  the  other,  in  the  large  majority  of  cases  that  nearest  the  pubes  being 
most  depressed,  so  that  the  sagittal  suture  is  felt  high  up  near  the  prom- 
ontory of  the  sacrum.  As  labor  advances,  if  the  contraction  is  not  too 
great  to  be  insuperable,  the  anterior  fontanelle  comes  much  more  within 
reach  than  in  ordinary  labor,  while  at  the  same  time  the  occipital  por- 
tion of  the  head  is  shoved  to  the  side  of  the  pelvis,  so  that  its  narrow 

'  Schroeder,  op.  cit.,  p.  256. 


DEFORMITIES  OF  THE  PELVIS.  391 

bi-tejiip.araljclianieter  engages  in  the  contracted  conjugate.  At  this  stage, 
on  examination,  it  will  be  found — supposing  we  have  to  do  with  a  case 
in  which  the  occiput  points  to  the  left  side  of  the  pelvis — that  the  ante- 
rior fontanelle  is  lower  than  the  posterior,  and  to  the  right,  the  bi-tem- 
poral  diameter  of  the  head  is  engaged  in  the  conjugate  diameter  of  the 
brim  (as  the  smallest  diameter  of  the  skull,  there  is  manifest  advantage 
in  this),  and  that  the  bi-parietal  diameter  and  the  largest  portion  of  the 
head  point  to  the  left  side.  The  sagittal  suture  will  be  felt  running 
across  in  the  transverse  diameter  of  the  brim,  but  nearer  to  the  sacrum, 
the  head  being  placed  obliquely.  As  the  head  is  forced  down  by  the 
uterine  contractions,  the  parietal  bone,  which  is  resting  on  the  promon- 
tory, is  pushed  against  it,  so  that  the  sagittal  suture  is  forced  more  into 
the  true  transverse  diameter  of  the  pelvic  brim  and  approaches  nearer 
to  the  pubes.  The  next  step  is  the  depression  of  the  head,  the  occiput 
undergoing;  a  sort  of  rotation  on  its  transverse  axis,  so  that  it  reaches  a 
plane  below  the  brim.  When  this  is  accomplished',  the  rest  of  the  head 
readily  passes  the  obstruction.  The  forehead  now  meets  with  the  resist- 
ance of  the  pelvic  walls,  the  posterior  fontanelle  descends  to  a  lower  level, 
and,  as  the  cavity  of  the  pelvis  in  cases  of  antero-posterior  contraction 
of  the  brim  is  generally  of  normal  dimensions,  the  rest  of  the  labor  is 
terminated  in  the  usual  way. 

In  Generalh/-contracted  Pelvis. — In  the  generally-contracted  pelvis 
the  head  enters  the  brim  with  the  posterior  fontanelle  lowest,  and  it  is 
after  it  -has  engaged  in  it  that  the  resistance  to  its  progress  becomes 
manifest.  The  result  is,  therefore,  an  exaggeration  of  what  is  met  with 
in  ordinary  cases.  The  resistance  to  the  anterior  or  longer  arm  of  the 
lever  is  greater  than  that  to  the  occipital  or  shorter,  and  therefore  the 
flexion  of  the  head  becomes  very  marked.  The  posterior  fontanelle  is 
consec|uently  unusually  depressed,  and  the  anterior  quite  out  of  reach. 
So  the  head  is  forced  down  as  a  wedge,  and  its  further  progress  must 
depend  upon  the  amount  of  contraction.  If  this  be  not  too  great,  the 
anterior  fontanelle  eventually  descends,  and  delivery  is  completed  in  the 
usual  way.  Should  the  contraction  be  too  much  to  permit  of  this,  the 
head  becomes  jammed  in  the  pelvis  and  diminution  of  its  size  may  be 
essential. 

In  cases  of  deformity  of  the  conjugate  diameter,  combined  with 
general  contraction  of  the  pelvis,  the  mechanism  partakes  of  the  pecu- 
liarities of  both  these  classes  to  a  greater  or  less  extent,  in  proportion  to 
the  preponderance  of  one  or  other  species  of  deformity. 

DiagnoniH. — It  rarely  happens  that  deformities  of  the  pelvis,  except 
of  the  gravest  kind,  are  suspected  before  labor  has  actually  commenced, 
and  tlierefore  we  are  not  often  called  upon  to  give  an  ojiinion  as  to  the 
condition  of  the  ])elvis  before  delivery.  Should  we  be,  tliere  are  various 
circumstances  wliich  may  aid  us  in  arriving  at  a  correct  conclusion. 
Prominent  among  them  is  the  history  of  the  patient  in  childhood.  If 
she  is  known  to  have  suffered  from  rickets  in  early  life,  more  especially 
if  tlic  disease  has  left  evident  traces  in  deformities  of  the  limbs  or  in  a 
dwarfed  and  stiuitc.'d  growth  or  in  curvature  of  the  sjiine,  there  will  })e 
strong  |)rcsuni|)tiv('  evidinicc  of  ])(;lvi(;  deformity  ;  a  markedly  ])endulous 
state  i)i'  the  abdomen  may  also  tend  to  confirm  the  suspicion.     Nothing 


392  LAB  OB. 

short  of  a  careful  examination  of  the  pelvis  itself  "v^•ill,  hoM^ever,  clear  up 
the  point  with  certainty ;  and  even  by  this  means  to  estimate  the  precise 
degree  of  deformity  with  accuracy  requires  considerable  skill  and  practice. 
The  ingenuity  of  practitioners  has  been  much  exercised — it  might  per- 
haps be  justly  said  wasted — in  the  invention  of  \'arious  more  or  less 
complicated  pelvimeters  for  aiding  us  in  obtaining  the  desired  object.  It 
is,  however,  pretty  generally  admitted  by  all  accoucheurs  that  the  hand 
forms  the  best  and  most  reliable  instrument  for  this  purpose — at  any 
rate,  as  regards  the  interior  of  the  pelvis — although  a  pair  of  callipers, 
such  as  Baudclocque's  well-known  instrument,  is  essential  for  accurately 
determining  the  external  measurements.  The  objections  to  all  internal 
pelvimeters,  even  those  most  simple  in  their  construction,  are  their  cost 
and  complexity  and  the  impossibility  of  using  them  without  pain  or 
injury  to  the  patient. 

External  Measurements. — It  was  formerly  thought  that  by  measuring 
the  distance  between  the  spinous  processes  of  the  sacrum  and  the  sym- 
physis pubis,  and  subtracting  from  it  what  we  judge  to  be  the  thickness 
of  the  bones  and  soft  parts,  we  might  arrive  at  an  approximate  estimate 
of  the  measurement  of  the  conjugate  diameter  of  the  pelvic  brim.  It  is 
now  admitted  that  this  method  can  never  be  depended  on,  and  that, 
taken  by  itself,  it  is  practically  useless.  A  change  in  the  relative  length 
of  other  external  measurements  of  the  pelvis  is,  however,  often  of  great 
value  in  showing  the  existence  of  deformity  internally,  although  not  in 
judging  of  its  amount.  The  measurements  which  are  used  for  this  pur- 
pose are  between  the  anterior-superior  spines  of  the  ilia  and  between  the 
centres  of  their  crests,  averaging  respectively  10  and  11  inches.  Accord- 
ing to  Spiegelberg,  these  measurements  may  give  one  of  three  results : 

1.  Both  may  be  less  than  they  ought  to  be,  but  the  relation  of  one  to 
the  other  remains  unchanged. 

2.  That  between  the  crests  is  not,  or  is  at  most  very  little,  diminished, 
but  that  between  the  spines  is  increased. 

3.  Both  are  diminished,  but  at  the  same  time  their  mutual  relation  is 
not  normal,  the  distance  between  the  spines  being  as  long,  if  not  longer, 
than  that  between  the  crests. 

No.  1  denotes  a  uniformly-contracted  pelvis ;  Xo.  2,  a  pelvis  simply 
contracted  in  the  conjugate  diameter  of  the  brim,  and  not  otherwise 
deformed ;  No.  3,  a  pelvis  with  narrowed  conjugate  and  also  uniformly 
contracted,  as  in  the  severe  type  of  rachitic  deformity.  If,  however, 
both  these  measurements  are  of  average  length,  and  the  distance  between 
the  crests  is  about  1  inch  greater  than  between  the  spines,  the  pelvis  is 
normal. 

Besides  the  above,  some  information  may  be  obtained  by  the  measure- 
ment of  the  external  conjugate  diameter,  which  averages  7f  inches. 
This  may  be  taken  by  placing  one  point  of  the  callipers  in  the  depres- 
sion below  the  spine  of  the  last  lumbar  vertebra,  the  other  at  the  centre 
of  the  upper  edge  of  the  symphysis  pubis.  If  the  measurement  be  dis- 
tinctly below  the  average — not  more,  for  example,  than  6.3  inches — we 
may  conclude  that  there  is  a  narrowing  of  the  antero-posterior  diameter 
of  the  brim,  the  extent  of  which  we  must  endeavor  to  ascertain  by  other 
means. 


DEFORMITIES  OF  THE  PELVIS. 


393 


For  the  purpose  of  making  these  measurements,  Baudelocque's  compas 
cVepaisseur  can  be  used,  or  Dr.  Lazarewitch's  elegant  universal  pelvim- 
eter, which  can  be  adopted  also  for  internal  pelvimetry ;  but  in  the 
absence  of  these  special  contrivances  an  ordinary  pair  of  callipers,  such 
as  are  used  by  carpenters,  can  be  made  to  answer  the  desired  object. 

Internal  Measuremenbi. — These  external  measurements  must  be  cor- 
roborated by  internal,  chiefly  of  the  antero-posterior  diameter,  by  which 
alone  we  can  estimate  the  amount  of  the  deformity.  We  endeavor  to 
find,  in  the  first  place,  the  length  of  the  inclined  conjugate  between  the 
lower  edge  of  the  symphysis  pubis  and  the  promontory  of  the  sacrum, 
which  averages  about  half  an  inch  more  than  the  true  conjugate.  This 
is  best  done  by  placing  the  patient  on  her  back  with  the  hips  well  raised. 
The  index  finger  of  the  right  hand  is  then  introduced  into  the  vagina, 
and  the  perineum  is  pressed  steadily  backward,  so  as  to  overcome  the 
resistance  it  offers.  If  the  tip  of  the  finger  can  reach  the  promontory  of 
the  sacrum,  its  radial  side  is  raised  so  as  to  touch  the  lower  edge  of  the 
pubes.  A  mark  is  made  with  the  nail  of  the  index  of  the  left  hand  on 
that  part  of  the  examining  finger  which  rests  under  the  symphysis,  and 
then  the  distance  from  this  to  the  tip  of  the  finger,  less  half  an  inch, 
may  be  taken  to  indicate  the  measurement  of  the  true  conjugate  of  the 
brim.  Various  pelvimeters  have  been  devised  to  make  the  same  meas- 
urements, such  as  Luraley  Earle's,  Lazarewitch's  (which  is  similar  in 
principle),  and  Van  Huevel's;  the  best  and  simplest,  I  think,  is  that 
invented  by  Dr.  Greenhalgh  (Fig.  141).  It  consists  of  a  movable  rod 
attached  to  a  flexible  band  of  metal 
Mdiich  passes  around  the  palm  of 
the  examining  hand.  At  the  distal 
end  of  the  rod  is  a  curved  portion 
which  passes  over  the  radial  edge 
of  the  index  finger.  The  examina- 
tion is  made  in  the  usual  way,  and 
when  the  point  of  the  finger  is  rest- 
ing on  the  promontory  of  the  sacrum 
the  rod  is  withdrawn  until  it  is 
arrested  by  the  posterior  surface  of 
the  symphysis,  the  exact  measure- 
ment of  the  inclined  conjugate  being 
then  read  off  the  scale. 

It  is  to  be  remembered  that  this 
procedure  is  useless  in  the  sligliter 
degrees  of  contraction  in  which  the 
promontory  of  the  sacrum  camiot 
be  easily  reached.  Dr.  Ramsbotham 
proposed  to  measure  the  conjugate 
by  spreading  out  the  index  and 
middle  fingers  internally,  the  tip  of 
one  resting  on  the  ])romontory,  tlu; 

other  behind  the  symphysis  ])ubis,  and  {\\v.n  withdrawing  them  in 
same  position  and  measui-ing  the;  distance  between  them.    This  manoeu- 
vre I  believe  to  be  impracticable. 


Greenlialgh's  relvinietcr. 


the 


394  LABOR. 

Whenever,  in  actual  labor,  we  wish  to  ascertain  the  condition  of  the 
pelvis  accurately,  the  patient  should  be  anaesthetized,  and  the  whole  hand 
introduced  into  the  vagina  (which  could  not  otherwise  be  done  without 
causing  great  pain),  and  the  proportions  of  the  pelvis  and  the  relations 
of  the  head  to  it  thoroughly  explored ;  and  if  what  has  been  said  as  to 
the  mechanism  of  delivery  in  these  cases  be  borne  in  mind,  this  may  aid 
us  in  determining  the  kind  of  deformity  existing.  In  this  way  contrac- 
tions about  the  outlet  of  the  pelvis  can  also  be  pretty  generally  made  out. 

Mode  of  Diagnosing  the  Oblique  Pelvis. — The  obliquely-contracted 
pelvis  cannot  be  determined  by  any  of  these  methods,  but  certain  exter- 
nal measurements,  as  Naegele  has  pointed  out,  will  readily  enable  us  to 
recognize  its  existence.  It  will  be  found  that  measurements  which  in 
the  healthy  pelvis  ought  to  be  equal  are  unequal  in  the  obliquely-distorted 
pelvis.  The  points  of  measurement  are  chiefly  :  (1)  From  the  tuber- 
osity of  the  ischium  on  one  side  to  the  posterior-superior  spine  of  the 
ilium  on  the  other ;  (2)  from  the  anterior-superior  iliac  spine  on  the  one 
side  to  the  posterior-superior  on  the  opposite ;  (3)  from  the  trochanter 
major  of  one  side  to  the  posterior-superior  iliac  spine  on  the  other ;  (4) 
from  the  lower  edge  of  the  symphysis  pubis  to  the  posterior-superior 
iliac  spine  on  either  side ;  (5)  from  the  spinous  process  of  the  last  lum- 
bar vertebra  to  the  anterior-superior  spine  of  the  ilium  on  either  side. 

If  these  measurements  differ  from  each  other  by  half  an  inch  to  an 
inch,  the  existence  of  an  obliquely-deformed  pelvis  may  be  safely  diag- 
nosed. The  diagnosis  can  Ibe  corroborated  by  placing  the  patient  in  the 
erect  position  and  letting  fall  two  plumb-lines — one  from  the  spines  of 
the  sacrum,  the  other  from  the  symphysis  pubis.  In  a  healthy  pelvis 
these  will  fall  in  the  same  plane,  but  in  the  oblique  pelvis  the  anterior 
line  will  deviate  considerably  toward  the  unaffected  side. 

Treatment. — The  proper  management  of  labor  in  contracted  pelvis  is, 
even  up  to  this  time,  one  of  the  most  vexed  questions  in  midwifery,  not- 
withstanding the  immense  amount  of  discussion  to  which  it  has  given 
rise ;  and  the  varying  opinions  of  accoucheurs  of  equal  experience  afford 
a  strong  proof  of  the  difficulties  surrounding  the  subject.  This  remark 
applies,  of  course,  only  to  the  lesser  degree  of  deformity,  in  which  the 
birth  of  a  living  child  is  not  hopeless.  When  the  antero-posterior  diam- 
eter of  the  brim  measures  from  2f  to  3  inches,  it  is  universally  admitted 
that  the  destruction  of  the  child  is  inevitable,  unless  the  pelvis  be  so 
small  as  to  necessitate  the  performance  of  the  Csesarean  section.  But 
when  it  is  between  3  inches  and  the  normal  measurement,  the  comjiara- 
tive  merits  of  the  forceps,  turning,  and  the  induction  of  premature  labor 
form  a  fruitful  theme  for  discussion.  With  one  class  of  accoucheurs  the 
forceps  is  chiefly  advocated,  and  turning  admitted  as  an  occasional 
resource  when  it  has  failed ;  and  this  indeed,  speaking  broadly,  may  be 
said  to  have  been  the  general  view  held  in  this  country.  More  recently 
we  find  German  authorities  of  eminence,  such  as  Schroeder  and  Spiegel- 
berg,  giving  turning  the  chief  place,  and  condemning  the  forceps  alto- 
gether in  contracted  pelvis,  or  at  least  restricting  its  use  within  very  nar- 
row limits.  More  strangely  still,  we  find  of  late  that  the  induction  of 
premature  labor,  on  the  origination  and  extension  of  which  British 
accoucheurs  have  always  prided  themselves,  is  placed  without  the  pale, 


DEFORMITIES  OF  THE  PELVIS.  395 

and  spoken  of  as  injurious  and  useless  in  reference  to  pelvic  deformities. 
To  see  our  way  clearly  amongst  so  many  conflicting  opinions  is  by  no 
means  an  easy  task,  and  perhaps  we  may  best  aid  in  its  accomplishment 
by  considering  separately  the  three  operations  in  so  far  as  they  bear  on 
this  subject,  and  pointing  out  briefly  what  can  be  said  for  and  against 
each  of  them. 

The  Forceps. — In  England  and  in  France  it  is  pretty  generally  admit- 
ted that  in  the  slighter  degrees  of  contraction  the  most  reliable  means  of 
aiding  the  patient  is  by  the  forceps.  It  should  be  remembered  that  the 
operation  under  such  circumstances  is  always  much  more  serious  than  in 
ordinary  labors  simply  delayed  from  uterine  inertia,  when  there  is  ample 
room  and  the  head  is  in  the  cavity  of  the  pelvas ;  for  the  blades  have  to 
be  passed  up  very  high,  often  when  the  head  is  more  or  less  movable 
above  the  brim,  and  much  more  traction  is  likely  to  be  required.  For 
these  reasons  artificial  assistance,  when  pelvic  deformity  is  suspected,  is 
not  to  be  lightly  or  hurriedly  resorted  to.  Nor,  fortunately,  is  it  always 
necessary,  for  if  the  pains  be  sufficiently  strong,  and  the  contraction  not 
too  great  to  prevent  the  head  engaging  at  all,  after  a  lapse  of  time  it 
will  become  so  moulded  in  the  brim  as  to  pass  even  a  considerable  ob- 
struction. In  all  cases,  therefore,  sufficient  time  must  be  given  for  this ; 
and  if  no  suspicious  symptoms  exist  on  the  part  of  the  mother — no  ele- 
vation of  temperature,  dryness  of  the  vagina,  rapid  pulse,  and  the  like, 
and  the  fcetal  heart-sounds  continue  to  be  normal — labor  may  be  allowed 
to  go  on  for  some  hours  after  the  rupture  of  the  membranes,  so  as  to 
give  nature  a  chance  of  completing  the  delivery.  When  this  seems 
hopeless  the  intervention  of  art  is  called  for. 

Cases  Suitable  for  the  Forceps. — The  forceps  is  generally  considered  to 
be  applicable  in  all  degrees  of  contraction,  from  the  standard  measure- 
ment down  to  about  3^  inches  in  the  conjugate  of  the  brim.  There  can 
be  no  doubt  that  in  such  cases  traction  with  the  forceps  often  enables  us 
to  effect  delivery  when  the  natural  efforts  have  proved  insufficient,  and 
holds'  out  a  very  fair  hope  of  saving  the  child.  Out  of  17  cases  in 
which  the  high  forceps  operation  was  resorted  to  for  pelvic  deformity, 
reported  by  Stanesco,  in  13  living  children  were  born.  If  the  length 
of  the  labor  and  the  long-continued  compression  to  which  the  child  has 
been  subjected  be  borne  in  mind,  this  result  must  be  considered  very 
favorable. 

Objections  that  have  been  liaised  to  the  Forceps. — What  are  the  objec- 
tions which  have  been  brought  against  the  operation  ?  These  have  been 
principally  made  ])y  Schroeder  and  other  German  writers.  They  are, 
chiefly,  the  difficulty  of  passing  the  instrument,  the  risk  of  injuring  the 
maternal  structures,  and  the  supposition  tliat,  as  the  blades  must  seize 
the  head  by  the  forehead  and  occiput,  their  compressive  action  will 
diminish  its  longitudinal  and  increase  its  transverse  diameter  (which  is 
opposed  to  the  contracted  part  of  the  brim),  and  so  enlarge  the  head  just 
Avhere  it  ought  to  l>e  smallest.  There  is  little  (loul)t  that  these  writers 
much  exaggerate  the  com])ressive  i)ower  of  the  forceps.  Certainly,  with 
those  generally  usc^d  in  this  conntry,  any  disadvantage  likely  to  accrue 
from  this  is  more  than  counterbalanced  l)y  the  tra(;tion  on  the;  head  ;  and 
the  fact  that  nn'nor  degrees  of  obstruction  can  be  thus  overcome  with  safety 


396  LABOR. 

both  to  the  mother  and  child  is  abundantly  proved  by  the  numberless 
cases  in  which  the  forceps  has  been  used. 

Not  equally  Suitable  in  all  Kinds  of  Deformity. — It  is  very  likely  that 
the  forceps  does  not  act  equally  well  in  all  cases.  When  the  head  is  loose 
above  the  brim ;  when  the  contraction  is  chiefly  limited  to  the  antero- 
posterior diameter,  and  there  is  abundance  of  room  at  the  sides  of  the 
pelvis  for  the  occiput  to  occupy  after  version  ;  and  when,  as  is  usual  in 
these  cases,  the  anterior  fontanelle  is  depressed  and  the  head  lies  trans- 
versely across  the  brim, — it  is  probable  that  turning  may  be  the  safer 
operation  for  the  mother,  and  the  easier  performed.  When,  on  the  other 
hand,  the  head  has  ensraared  in  the  brim  and  has  become  more  or  less 
impacted,  it  is  obvious  that  version  could  not  be  performed  without 
pushing  it  back,  which  may  be  neither  easy  nor  safe.  In  the  generally- 
contracted  pelvis,  in  which  the  head  enters  in  an  exaggerated  state  of 
flexion  and  lies  obliquely,  the  posterior  fontanelle  being  much  depressed, 
the  forceps  is  more  suitable. 

Mechanical  Advantage  of  Turning  in  Certain  Cases. — The  special 
reasons  why  version  sometimes  succeeds  when  the  forceps  fails,  or  why 
it  may  be  elected  from  the  first  as  a  matter  of  choice,  have  been  by  no 
one  better  pointed  out  than  by  Sir  James  Simpson.  Although  the  ope- 
ration was  performed  by  many  of  the  older  obstetricians,  its  revival  in 
modern  times  and  the  clear  enunciation  of  its  principles  can  undoubtedly 
be  traced  to  his  writings.  He  points  out  that  the  head  of  the  child  is 
shaped  like  a  cone,  its  narrowest  portion  the  base  of  the  cranium  (Fig. 
142,  h  b),  measuring,  on  an  average,  from  -^  to  f  of  an  inch  less  than 
the  broadest  portion  (Fig.  142,  a  a) — viz.  the  bi-parietal  diameter.     In 


Fig.  143. 


Fig.  142. 


Section  of  Fretal  Cranium,  showing  Showing  the  Greater  Breadth  of  the 

its  Conical  Form.  Bi-parietal  Diameter  of  the  Fcetal 

Cranium.    (After  Simpson.) 

ordinary  head  presentations  the  latter  part  of  the  head  has  to  pass  first ; 
but  if  the  feet  are  brought  down,  the  narrow  apex  of  the  cranial  cone  is 
brought  first  into  apposition  with  the  contracted  brim,  and  can  be  more 
easily  drawn  through  than  the  broader  base  can  be  pushed  through  by 
the  uterine  contractions.  Nor  is  this  the  only  advantage,  for  after  turn- 
ing the  narrower  bi-temporal  diameter  (Fig.  143,  6  b) — which  measures, 
on  an  average,  half  an  inch  less  than  the  bi-parietal  (Fig.  143,  «  a) — is 
brought  into  contact  with  the  contracted  conjugate,  while  the  broader  bi- 
parietal  lies  in  the  comparatively  wide  space  at  the  side  of  the  pelvis 


DEFORMITIES  OF  THE  PELVIS.  397 

(Fig.  144).  These  mechanical  considerations  are  sufficiently  obvious, 
and  fully  explain  the  success  which  has  often  attended  the  performance 
of  the  operation. 

Limits  of  the  Operation. — It  is  generally  admitted  that  it  may  be  pos- 
sible, for  the  reasons  just  mentioned,  to  deliver  a  living  child  by  turning 

Fig.  144. 


Showing  the  Greater  Space  for  the  Bi-parietal  Diameter  at  the  Side  of  the  Pelvis  in  Certain 
Cases  of  Deformity.    (After  Simpson.) 

through  a  pelvis  contracted  beyond  the  point  which  would  permit  of  a 
living  child  being  extracted  by  the  forceps.  Many  obstetricians  believe 
that  it  is  possible  to  deliver  a  living  child  by  turning  in  a  pelvis  con- 
tracted even  to  the  extent  of  2|-  inches  in  the  conjugate  diameter.  Barnes 
maintains  that,  although  an  unusually  compressible  head  may  be  drawn 
through  a  pelvis  contracted  to  3  inches,  the  chance  of  the  child  being 
born  alive  under  such  circumstances  must  necessarily  be  small,  and  that 
from  3^  inches  to  the  normal  size  must  be  taken  as  the  proper  limits  of 
the  operation. 

It  frequently  Succeeds  when  the  Forceps  has  Failed. — That  delivery  is 
often  possible  by  turning  after  the  forceps  and  the  natural  powers  have 
failed,  and  when  no  other  resource  is  left  but  the  destruction  of  the  child, 
must,  I  think,  be  admitted  by  all,  for  the  records  of  obstetrics  are  full 
of  such  cases.  To  take  one  example  only  :  Dr.  Braxton  Hicks  ^  records 
four  cases  in  which  the  forceps  were  tried  unsuccessfully,  in  all  of  which 
version  was  used,  three  of  the  children  being  born  alive.  Here  are  the 
lives  of  three  children  rescued  from  destruction  within  a  sliort  period  in 
the  practice  of  one  man ;  and  a  fact  like  this  would  of  itself  be  ample 
justification  of  the  attempt  to  deliver  by  turning  when  the  child  was 
known  to  be  alive  and  other  means  had  failed.  The  possibility  that 
craniotomy  may  still  be  required  is  no  argument  against  the  operation ; 
for  altliougli  perforation  of  the  after-coming  head  is  certainly  not  so  easy 
as  perforation  of  a  presenting  head,  it  is  not  so  much  more  difficult  as  to 
justify  the  n(3glect  of  an  exjieriment  by  which  it  may  possibly  be  alto- 
gether avoided. 

Comparative  Estimate  of  the  Two  Operations. — The  original  chcjice  of 
turning  is  a  more  difficult  question  to  decide.      The  most  generally  ', 
received  opinion  in  tlie  j^resent  day  amongst  scientific;  o})stctricians  is 
that  in  tlie  simply  flattened  jx'lvis,  with  an  antero-])osterior  diameter  of 
not  less  than  2-|  inches,  tiu'iiing  is  the  preferable  operation.     In  every 

1  QwJh  Hoxpitnl  Rrporl^,  1 870. 


398  LABOR. 

case  of  doubt  it  is  desirable  thoroughly  to  auresthetize  the  patient  and 
make  a  careful  examination  with  the  whole  hand  in  the  vagina.  If  we 
find  the  sagittal  suture  laying  transversely,  one  parietal  bone  on  a  lower 
line  than  the  other,  and  if  both  fontanelles  are  easily  within  reach,  and 
some  space  exists  at  the  sides  of  the  pelvis  beside  the  forehead  and  occi- 
put, then  turning  is  the  procedure  most  likely  to  succeed,  and  the  descent 
of  the  head  after  version  can  be  very  materially  assisted  by  strong  pres- 
sure applied  from  above  by  an  assistant,  as  has  been  well  pointed  cnit  by 
Gooclell/  If,  on  the  other  hand,  the  anterior  fontanelle  is  high  up  and 
out  of  reach,  the  head  being  distinctly  flexed,  we  have  to  do  with  a  gen- 
erally-contracted pelvis,  and  the  forceps  is  the  preferable  operation. 

Cases  in  which  Craniotomy  or  the  Qesarean  Section  is  Beqnired. — 
When  the  contraction  is  below  3  inches  in  the  conjugate,  or  when  the 
forceps  and  turning  have  failed,  no  resource  is  left  but  the  destruction  of 
the  foetus  or  the  Csesarean  section. 

The  induction  of  premature  labor  as  a  means  of  avoiding  the  risks  of 
delivery  at  term,  and  of  possibly  saving  the  life  of  the  child,  must  now " 
be  studied.  The  established  rule  in  this  country  is,  that  in  all  cases  of 
pelvic  deformity,  the  existence  of  which  has  been  ascertained  either  by 
the  experience  of  former  labors  or  by  accurate  examination  of  the  pelvis,, 
labor  should  be  induced  previous  to  the  full  period,  so  that  the  smaller 
and  more  compressible  head  of  the  premature  foetus  may  pass  where 
that  of  the  foetus  at  term  could  not.  The  gain  is  a  double  one — partly 
the  lessened  risk  to  the  mother,  and  partly  the  chance  of  saving  the 
child's  life. 

Recent  Objections  to  it. — The  practice  is  so  thoroughly  recognized  as  a 
conservative  and  judicious  one  that  it  might  be  hardly  necessary  to  argue 
in  its  favor,  were  it  not  that  some  eminent  authorities  have  of  late  years 
tried  to  show  that  it  is  better  and  safer  to  the  mother  to  leave  the  labor  to 
come  on  at  term,  and  that  the  risk  to  the  child  is  so  great  in  artificially- 
induced  labor  as  to  lead  to  the  conclusion  that  the  operation  should  be 
altogether  abandoned,  except,  perhaps,  in  the  extreme  distortion  in  which 
the  Csesarean  section  might  otherwise  be  necessary.  Prominent  amongst 
those  who  hold  these  views  are  Spiegelberg  and  Litzmann  ;  and  they 
have  been  sui)ported,  in  a  modified  form,  by  Matthews  Duncan.  Spie- 
gelberg^ tries  to  show,  by  a  collection  of  cases  from  various  sources,  that 
the  results  of  induced  labor  in  contracted  pelvis  are  much  more  unfavor- 
able than  when  the  cases  are  left  to  nature — that  in  the  latter  the  mor- 
tality of  the  mothers  is  6.6  per  cent.,  and  of  the  children  28.7  per  cent., 
whereas  in  the  former  the  maternal  deaths  are  15  per  cent.,  and  the 
infantile  66.9  per  cent.  Litzmann^  arrives  at  not  very  dissimilar  results 
— namely,  6.9  per  cent,  of  the  mothers  and  20.3  per  cent,  of  the  children 
in  contracted  pelvis  at  term,  and  14.7  ]x>r  cent,  of  the  mothers  and  55.8 
per  cent,  of  the  children  in  artificially-induced  premature  labor. 

If  these  statistics  were  reliable,  inasmuch  as  they  show  a  very  decided 
risk  to  the  mother,  there  might  be  great  force  in  the  argument  that  it 
would  be  better  to  leave  the  cases  to  run  the  chance  of  delivery  at  term. 
It  is,  however,  very  questionable  whether  they  can  be  taken,  in  them- 

^Amer.  Journ.  of  Obstet.,  vol.  viii.  "^  Arch.  J.  Gyn.,  B.  i.  S.  1. 

3  lb.,  B.  ii.  S.  169. 


DEFORMITIES  OF  THE  PELVIS.  399 

selves,  as  being  sufficient  to  settle  the  question.  The  fallacy  of  deter- 
mining such  points  by  a  mass  of  heterogeneous  cases,  collected  together 
without  a  careful  sifting  of  their  histories,  has  over  and  over  again  been 
pointed  out ;  and  it  would  be  easy  enough  to  meet  them  by  an  equal 
catalogue  of  cases  in  which  the  maternal  mortality  is  almost  nil.  The 
results  of  the  practice  of  many  authorities  are  given  in  Churchill's  work, 
where  we  find,  for  example,  that  out  of  46  cases  of  Merriman's  not  one 
proved  fatal.  The  same  fortunate  result  happened  in  62  cases  of  Rams- 
botham's.  His  conclusion  is  that  "there  is  undoubtedly  some  risk 
incurred  by  the  mother,  but  not  more  than  by  accidental  premature 
labor ; "  and  this  conclusion  as  regards  the  mother  is  that  which  has  long 
ago  been  arrived  at  by  the  majority  of  British  obstetricians,  who  un- 
doubtedly have  more  experience  of  the  operation  than  those  of  any  other 
nation.  With  regard  to  the  child,  even  if  the  German  statistics  be  taken 
as  reliable,  they  would  hardly  be  accepted  as  contraindicating  the  opera- 
tion, inasmuch  as  it  is  intended  to  save  the  mother  from  the  dangers  of 
the  more  serious  labor  at  term,  and  in  many  cases  to  give  at  least  a 
chance  to  the  child,  whose  life  would  otherwise  be  certainly  sacrificed. 
The  result,  moreover,  must  depend  to  a  great  extent  on  the  method  of 
operation  adopted,  for  many  of  the  plans  of  inducing  labor  recommended 
are  certainly,  in  themselves,  not  devoid  of  danger  both  to  the  mother  and 
the  child.  It  may,  I  think,  be  admitted,  as  Duncan  contends,^  that  the 
operation  has  been  more  often  performed  than  is  absolutely  necessary, 
and  that  the  higher  degrees  of  pelvic  contraction  are  much  more  uncom- 
mon than  has  been  supposed  to  be  the  case.  That  is  a  very  valid  reason 
for  insisting  on  a  careful  and  accurate  diagnosis,  but  not  for  rejecting  an 
operation  which  has  so  long  been  an  established  and  favorite  resource. 

Determination  of  Period  for  Inducing  Labor. — When  the  induction 
of  labor  has  been  determined  on,  the  precise  period  at  which  it  should 
be  resorted  to  becomes  a  question  for  anxious  consideration,  since  the 
longer  it  is  delayed  the  greater,  of  course,  are  the  dangers  for  the  child. 
Many  tables  have  been  constructed  to  guide  us  on  this  point  which  are 
not,  on  the  whole,  of  so  much  service  as  they  might  appear  to  be,  on 
account  of  the  difficulty  of  determining  with  minute  accuracy  the  amount 
of  contraction.  The  following,  however,  which  is  drawn  up  by  Kiwisch, 
may  serve  for  a  guide  in  settling  this  question  : 

Inches.         Lines. 
When  the  sacro-pubic  diameter  is  2  and    6  or    7,  induce  labor  at  30th  week. 


2    "      8  " 

9, 

" 

31st 

2    "     10  " 

lb 

" 

32d 

3    "       .  .  , 

'' 

33d 

3    "           1, 

" 

33d 

3    "      2  " 

3, 

u 

34th 

3    "      4  " 

5, 

" 

35th 

3    "      5  " 

6, 

" 

36th 

In  cases  of  moderate  deformity,  when  labor-pains  have  been  induced, 
the  further  progress  of  the  case  may  be  left  to  nature ;  but  in  more 
marked  cases,  as  in  those  below  3  inches,  it  will  often  be  found  neces- 
sary to  assist  delivery  by  turning  or  by  the  forceps,  the  former  being 
'  Edin.  Med.  Journ.,  July,  1873,  p.  339. 


400  LABOR. 

here  specially  useful,  on  account  of  the  extreme  pliability  of  the  head 
and  the  facility  with  which  it  may  be  drawn  through  the  contracted 
brim.  By  thus  combining  the  two  operations  it  may  be  quite  possible 
to  secure  the  birth  of  a  living  child  even  in  pelves  very  considerably 
deformed. 

Production  of  Abortion  in  Extreme  Deformity. — When  the  contraction 
is  so  great  as  to  necessitate  the  induction  of  the  labor  before  the  sixth 
month — or,  in  other  words,  before  the  child  has  reached  a  viable  age — 
it  would  be  preferable  to  resort  to  a  very  early  production  of  abortion. 
The  operation  is  then  indicated,  not  for  the  sake  of  the  child,  but  to 
save  the  mother  from  the  deadly  risk  to  which  she  would  otherwise  be 
subjected.  As  in  these  cases  the  mother  alone  is  concerned,  the  opera- 
tion should  be  performed  as  soon  as  we  have  positively  determined  the 
existence  of  pregnancy.  No  object  can  be  gained  by  waiting  until  the 
development  of  the  child  is  advanced  to  any  extent,  and  the  less  the 
foetus  is  developed  the  less  will  be  the  pain  and  risks  the  mother  has 
to  undergo.  There  is  no  amount  of  deformity,  however  great,  in  which 
we  could  not  succeed  in  bringing  on  miscarriage  by  some  of  the  numer- 
ous means  at  our  disposal ;  and,  in  spite  of  Dr.  Radford's  objections, 
who  maintains  that  the  obstetrician  is  not  justified  in  sacrificing  the  life 
of  a  human  being  more  than  once  when  the  mother  knows  that  she  can- 
not give  birth  to  a  viable  child,  there  are  few  practitioners  who  would 
not  deem  it  their  duty  to  spare  the  mother  the  terrible  dangers  of  the 
Osesarean  section. 


CHAPTER   XIII. 

HEMORKHAGE   BEFORE   DELIVERY;    PLACENTA    PRiEVIA. 

The  hemorrhages  which  are  the  result  of  an  abnormal  situation  of 
the  placenta,  partially  or  entirely,  over  the  internal  os  uteri  have  formed 
a  most  fruitful  theme  for  discussion.  The  explanation  of  the  abnormal 
placental  site,  the  sources  of  the  blood,  and  the  causes  of  its  escape,  the 
means  adopted  by  nature  for  its  arrest,  and  the  proper  treatment,  have, 
each  and  all  of  them,  been  the  subject  of  endless  controversies,  ^^hich 
are  not  yet  by  any  means  settled.  It  must  be  admitted,  too,  that  the 
extreme  importance  of  the  subject  amply  justifies  the  attention  which 
has  been  paid  to  it,  for  there  is  no  obstetric  complication  more  aj)t  to 
produce  sudden  and  alarming  eifects,  and  none  requiring  more  prompt 
and  scientific  treatment. 

Definition. — By  placenta  proevia  we  mean  the  insertion  of  the  placenta 
at  the  lower  segment  of  the  uterine  cavity,  so  that  a  portion  of  it  is  situ- 
ated, wholly  or  partially,  over  the  internal  os  uteri.  In  the  former  case 
there  is  complete  or  central  placental  presentation,  in  the  latter  an  incom- 
plete or  marginal  presentation. 

Chuses. — The  causes  of  this  abnormal  placental  site  are  not  fully 


HEMOBBHAGE  BEFOBE  DELIVEBY.  401 

understood.  It  was  supposed  by  Tyler  Smith  to  depend  on  the  ovule 
not  having  been  impregnated  until  it  had  reached  the  louver  part  of  the 
uterine  cavity.  Cazeaux  suggests  that  the  uterine  mucous  membrane 
is  less  swollen  and  turgid  than  when  impregnation  occurs  at  the  more 
ordinary  place,  and  that,  therefore,  it  offers  less  obstruction  to  the  de- 
scent of  the  ovule  to  the  lower  part  of  the  uterine  cavity.  An  abnormal 
size  or  unusual  shape  of  the  uterine  cavity  may  also  favor  the  descent 
of  the  impregnated  ovule ;  the  former  probably  explains  the  fact  that 
placenta  prsevia  more  generally  occurs  in  v\^omen  ^\\\o  have  already 
borne  children.  Muller  believes  that  it  results  from  uterine  contrac- 
tions occurring  shortly  after  conception,  which  force  the  ovum  down  to 
the  lower  part  of  the  uterine  cavity.  These  are  merely  interesting  specu- 
lations, having  no  practical  value,  the  fact  being  undoubted  that  in  a  not 
inconsiderable  number  of  cases — estimated  by  Johnson  and  Sinclair  as  1 
out  of  573 — the  placenta  is  grafted  partially  or  entirely  over  the  uterine 
orifice. 

History. — Placenta  prsevia  was  not  unknown  to  the  older  writers, 
who  believed  that  the  placenta  had  originally  been  situated  at  the 
fundus,  from  which  it  had  accidentally  fallen  to  the  lower  part  of  the 
uterus.  Portal,  Levret,  Roederer,  and  especially  our  own  countryman 
Rigby,  were  among  those  whose  observations  tended  to  improve  the 
state  of  obstetrical  knowledge  as  to  its  real  nature.  To  Pigby  we  owe 
the  term  "  unavoidable  hemorrhage  "  as  a  synonym  for  placenta  prsevia, 
and  as  distinguishing  hemorrhage  from  this  source  from  that  resulting 
from  separation  of  the  placenta  at  its  more  usual  position,  termed  by 
him,  in  contradistinction,  "  accidental  hemorrhage."  These  names, 
adopted  by  most  writers  on  the  subject,  are  obviously  misleading,  as 
they  assume  an  essential  distinction  in  the  etiology  of  the  hemorrhage 
in  the  two  classes  of  cases  which  is  not  always  warranted. 

It  is  of  the  utmost  importance  to  a  right  understanding  of  the  nature 
and  treatment  of  placenta  prsevia  that  we  should  fully  understand  the 
source  of  the  hemorrhage  and  the  manner  of  its  production ;  but  we 
shall  be  able  to  discuss  this  subject  better  after  a  description  of  the 
symptoms. 

Symptoms. — Although  the  placenta  must  occupy  its  unusual  site  from 
the  earliest  period  of  its  formation,  it  rarely  gives  rise  to  appreciable 
symjitoms  before  the  last  three  months  of  utero-gestation.  It  is  far  from 
unlikely,  however,  that  such  an  abnormal  situation  of  the  placenta  may 
produce  abortion  in  the  earlier  months,  the  site  of  its  attachment  pass- 
ing unobserved. 

SiifJden  Flow  of  Blood,. — The  earliest  symptom  which  causes  suspicion 
is  the  sudden  occurrence  of  hemorrhage  without  any  appreciable  cause. 
The  amount  of  blood  lost  varies  considerably.  In  some  cases  the  first 
hemorrhage  is  com])arativcly  slight,  and  is  soon  spontaneously  arrested ; 
but  if  the  case  be  left  to  itself,  the  fio^v  after  a  lapse  of  time — it  may  be 
a  few  days  or  it  may  be  weeks — again  commences  in  the  same  unex- 
pected way,  and  each  successive  hemorrhage  is  more  ]irofuse.  The 
losses  show  themselves  at  different  jieriods.  They  rarely  begin  befi)re 
the  end  of  tlie  sixtli  montli,  more  often  nearer  the  full  period,  and  some- 
times not  until  labor  has  actually  commenced.  The  hemorrhage  very 
2G 


402  LABOR. 

often  coincides  with  what  would  have  been  a  menstrual  period,  doubt- 
less on  account  of  the  physiological  congestion  of  the  uterine  organs 
then  present.  Should  the  first  loss  not  show  itself  until  at  or  near  the 
full  time,  it  may  be  tremendous,  and  a  few  moments  may  suffice  to 
place  the  patient's  life  in  jeopardy.  Indeed,  it  may  be  safely  accepted 
as  an  axiom  that  once  hemorrhage  has  occurred  the  patient  is  never 
safe,  for  excessive  losses  may  occur  at  any  moment  without  warning 
and  when  assistance  is  not  at  hand.  It  often  happens  that  j^remature 
labor  comes  on  after  one  or  more  hemorrhages. 

In  any  case  of  placenta  prsevia  when  labor  lias  commenced,  whether 
premature  or  at  the  full  time,  the  hemorrhage  may  become  excessive, 
and  with  each   pain   fresh  portions  of  placenta  may  be  detached  and 
I  fresh  vessels  torn  and  left  open.     Under  these  circumstances  the  blood 
I  often  escapes  in  greater  quantity  with  each  successive  pain,  and  dimin- 
ishes in  the  interval.     This  has  long  been  looked  upon  as  a  diagnostic 
mark  by  which  we  can  distinguish  between  the  so-called  "  unavoidable" 
and  "  accidental "  hemorrhage ;  in   the  latter  the  flow  being  arrested 
during  the  pains.     The  distinction,  however,  is  altogether   fallacious. 
/  The  tendency  of  uterine  contraction  in  placenta  prsevia,  as  in  all  other 
\  forms  of  uterine  hemorrhage,  is  to  constrict  the  vessels  from  Avhich  the 
1  blood  escapes,  and  so  to  lessen  the  flow.     The  apparently  increased  flow 
during   the  pains  depends  on  the  pains  forcing  out  blood  which  has 
already  escaped  from  the  vessels.     In  one  way,  up  to  a  certain  point, 
the  pains  do  favor  hemorrhage  by  detaching  fresh  portions  of  placenta  ; 
but  the  actual   loss  takes  place  chiefly  during  the  intervals,  and  not 
during  the  continuance  of  contraction. 

Results  of  Vaginal  Examination. — On  vaginal  examination,  if  the  os 
be  sufficiently  open  to  admit  the  finger — which  it  generally  is,  on  ac- 
count of  the  relaxation  produced  by  the  loss  of  blood — we  shall  almost 
ahvays  be  able  to  feel  some  portion  of  presenting  placenta.  If  it  be  a 
central  implantation,  we  shall  find  the  upper  aperture  of  the  cervix 
entirely  covered  by  a  thick,  boggy  mass,  which  is  to  be  distinguished 
from  a  coagulum  by  its  consistence  and  by  its  not  breaking  down  under 
the  pressure  of  the  finger.  Through  the  placental  mass  we  may  feel  the 
presenting  part  of  the  foetus,  but  not  as  distinctly  as  when  there  is  no 
intervening  substance.  In  partial  placental  presentations  the  bag  of 
membranes,  and  above  it  the  head  or  other  presentation,  will  be  found 
to  occupy  a  part  of  the  circle  of  the  os,  the  rest  being  covered  by  the 
edge  of  the  placenta.  In  marginal  presentations  Ave  may  only  be  able  to 
make  out  the  thickened  edge  of  the  after-birth  projecting  at  the  rim  of 
the  OS,  If  the  cervix  be  high  and  the  gestation  not  advanced  to  term, 
these  points  may  not  be  easy  to  make  out  on  account  of  the  difficulty  of 
reaching  the  cervix  ;  and,  as  accurate  diagnosis  is  of  the  utmost  im})ort- 
ance,  it  is  proper  to  introduce  two  fingers,  or  even  the  whole  hand,  so  as 
thoroughly  to  explore  the  condition  of  the  parts.  The  lower  portion  of 
the  uterine  ovoid  may  be  observed  to  be  more  than  usually  thick  and 
fleshy ;  and  Gendrin  has  pointed  out  that  ballottement  cannot  be  made 
out.  The  accuracy  of  our  diagnosis  may  be  confirmed,  in  doubtful 
cases,  by  finding  that  the  placental  bruit  ie  heard  over  the  lower  part  of 
the  uterine  tumor. 


HEMORRHAGE  BEFORE  -DELIVERY.  403 

Dr.  Wallace^  has  suggested  that  vaginal  auscultation  may  be  service- 
able in  diagnosis,  and  states  that  by  means  of  a  curved  wooden  stetho- 
scope the  placental  bruit  may  be  heard  with  startling  distinctness.  This 
is,  however,  a  manoeuvre  that  can  hardly  be  generally  carried  out  in 
actual  practice. 

The  Source  of  Hemorrhage. — It  is  now  generally  admitted  by  author- 
ities that  the  immediate  source  of  the  hemorrhage  is  the  lacerated  utero- 
_placental_vessels.  Only  a  few  years  ago  Sir  James  Simpson  advocated 
with  his  usual  energy  the  theory,  sustained  by  his  predecessor,  Dr. 
Hamilton,  that  the  chief  if  not  the  only  source  of  hemorrhage  was  the 
detached  portion  of  the  placenta  itself.  He  argued  that  the  blood  flowed 
from  the  portion  of  the  placenta  which  was  still  adherent  into  that  which 
was  separated,  and  escaped  from  the  surface  of  the  latter ;  and  on  this 
supposition  he  based  his  practice  of  entirely  separating  the  placenta, 
having  observed  that  in  many  cases  in  which  the  after-birth  had  been 
expelled  before  the  child  the  hemorrhage  had  ceased.  The  fact  of  the 
cessation  of  the  hemorrhage,  when  this  occurs,  is  not  doubted,  but  Simj)- 
son's  explanation  is  contested  by  most  modern  writers,  prominent  among 
whom  is  Barnes,  who  has  devoted  much  study  to  the  elucidation  of  the 
subject.  He  points  out  that  the  stoppage  of  the  hemorrhage  is  not  due 
to  the  separation  of  the  placenta,  but  to  the  preceding  or  accompanying 
contraction  of  the  uterus,  which  seals  up  the  bleeding  vessels,  just  as  it 
does  in  other  forms  of  hemorrhage.  The  site  of  the  loss  was  actually 
demonstrated  by  the  late  Dr.  Mackenzie  in  a  series  of  experiments  in 
which  he  partially  detached  the  placenta  in  pregnant  bitches,  and  found 
that  the  blood  flowed  from  the  walls  of  the  uterus,  and  not  from  the 
detached  surface  of  the  placenta.  The  arrangement  of  the  large  venous 
sinuses,  opening  as  they  do  on  the  uterine  mucous  membrane,  favors  the 
escape  of  blood  when  they  are  torn  across  ;  and  it  is  from  them,  possibly 
to  some  extent  also  from  the  uterine  arteries,  that  the  blood  comes,  just 
as  in  post-partum  hemorrhage,  when  the  whole  instead  of  a  part  of  the 
placental  site  is  bared. 

Causes  of  Hemorrhage. — Various  explanations  have  been  given  of  the 
causes  of  the  hemorrhage.  It  was  long  supposed  to  depend  on  the 
gradual  expansion  of  the  cervix  during  the  latter  months  of  pregnancy, 
wliich  separated  the  abnormally  placed  placenta.  It  has  been  seen, 
however,  that  this  shortening  of  the  cervix  is  apparent  only,  and  that 
the  cervical  canal  is  not  taken  up  into  the  uterine  cavity  during  gesta- 
tion, or,  at  all  events,  only  during  the  last  week  or  so.  This,  therefore, 
cannot  be  admitted  as  an  explanation  of  placental  separation.  Jacque- 
mier  proposed  another  theory,  which  has  been  adopted  by  Cazeaux. 
He  maintains  that  dnring  the  first  six  months  of  utero-gestation  the 
superior  portion  of  the  uterus  is  more  especially  developed,  as  shown  by 
tlie  pyriform  shape  of  the  fundus  during  the  time,  and  that,  as  the  pla- 
centa is  usually  attached  in  that  situation,  and  then  attains  its  maximum 
of  development,  its  relations  to  its  attachments  are  unch'sturbcd.  Dur- 
ing the  last  tliree  montlis  f)f  pregnancy,  on  the  contrary,  tlu;  lower  seg- 
ment of  tlie  uterus  develops  more  than  the  upper,  while  the  ])lacenta 
remains  nearly  stationary  in  size,  the  inevitable  result  being  a  loss  of 

1  Edin.  Med.  Journ.,  Nov.,  1872. 


404  LABOR. 

proportion  between  tlie  cervix  and  the  placenta,  and  the  detachment  of 
the  latter.  There  are  various  objections  which  can  be  brought  against 
this  theory,  the  most  important  being  that  there  is  no  evidence  at  all  to 
show  that  the  lower  segment  of  the  uterus  does  expand  more  in  propor- 
tion than  the  upper  during  the  latter  months  of  pregnancy.  Barnes's 
theory  is  based  on  the  supposition  that  the  loss  of  relation  between  the 
uterus  and  placenta  is  caused  by  excess  of  growth  on  the  part  of  the 
placenta  itself  over  that  of  the  cervix,  which  is  not  adapted  for  its 
attachment.  The  placenta,  on  this  hypothesis,  grows  away  from  the 
site  of  its  attachment,  and  hemorrhage  results.  It  will  be  observed  that 
neither  this  theory  nor  that  propounded  by  Jacquemier  is  readily  recon- 
cilable with  the  fact  that  hemorrhage  frequently  does  not  begin  until 
labor  has  commenced  at  term.  Inasmuch  as  the  loss  of  relation  between 
the  placenta  and  its  attachments,  which  they  both  presuppose,  must  exist 
in  every  case  of  placenta  prsevia,  hemorrhage  should  always  occur  dur- 
ing some  part  of  the  last  three  months  of  pregnancy.  Matthews  Dun- 
can ^  has  recently  investigated  the  whole  subject  at  length,  and  maintains 
that  the  hemorrhages  are  accidental,  not  unavoidable,  being  due  to 
causes  precisely  similar  to  those  which  give  rise  to  the  occasional  hemor- 
rhages when  the  placenta  is  normally  placed.  The  abnormal  situation 
of  the  placenta  of  course  renders  these  causes  more  apt  to  operate ;  but 
in  their  action  he  believes  them  to  be  precisely  similar  to  those  of  acci- 
dental hemorrhage,  properly  so  called.  Separation  of  the  placenta  from 
expansion  of  the  cervix  he  believes  to  be  the  cause  of  hemorrhage  after 
labor  has  begun,  and  then  it  may  strictly  be  called  unavoidable ;  but 
hemorrhage  is  comparatively  seldom  so  produced  during  the  continuance 
of  pregnancy.  "  There  are,"  says  Duncan,  "  four  ways  in  which  this 
kind  of  hemorrhage  may  occur : 

"  1.  By  the  rupture  of  a  utero-placental  vessel  at  or  about  the  inter- 
nal OS  uteri. 

"  2.  By  the  rupture  of  a  marginal  utero-placental  sinus  within  the 
area  of  spontaneous  premature  detachment  "s^  hen  the  placenta  is  inserted 
not  centrally  or  covering  the  internal  os,  but  with  a  margin  at  or  near 
the  internal  os. 

"  3.  By  partial  separation  of  the  placenta  from  accidental  causes,  such 
as  a  jerk  or  fall. 

*  "4.  By  a  partial  separation  of  the  placenta  the  consequence  of  uterine 
pains,  producing  a  small  amount  of  dilatation  of  the  internal  os.  Such 
cases  may  be  otherwise  described  as  instances  of  miscarriage  commen- 
cing, but  arrested  at  a  very  early  stage." 

I  see  no  reason  to  doubt  the  possibility  of  hemorrhage  being  due  in 
many  cases  to  the  first  three  causes,  and  in  its  production  it  would 
strictly  resemble  accidental  hemorrhage.  The  fourth  heading  refers  the 
hemorrhage  to  partial  separation  in  consequence  of  commencing  dilata- 
tion of  the  cervix,  but  it  explains  the  dilatation  by  the  supposition  of 
commencing  miscarriage.  This  latter  hypothesis  seems  to  be  as  needless 
as  those  which  presuppose  a  want  of  relation  between  the  placenta  and 
its  attachments.  We  know  that,  quite  independently  of  commencing 
miscarriage,  uterine  contractions  are  constantly  occurring  during  the 
'■  Edin.  Med.  Journ.,  Nov.,  1873,  and  Brit.  Med.  Journ.,  Nov.,  1873. 


HEMORRHAGE  BEFORE  DELIVERY.  405 

continuance  of  pregnancy.  There  is  no  reason  to  suppose  that  these 
contractions  do  not  aifect  the  cervical  as  well  as  the  fundal  portions  of 
the  uterus ;  and  in  cases  in  which  the  placenta  is  situated  partially  or 
entirely  over  the  os,  one  or  more  stronger  contractions  than  usual  may 
at  any  moment  produce  laceration  of  the  placental  attachments  in  that 
neighborhood. 

Pathological  Changes  in  the  Placenta. — A  careful  examination  of  the 
placenta  may  show  pathological  changes  at  the  site  of  separation,  such  as 
have  been  described  by  Gendrin,  Simpson,  and  other  writers.  They 
probably  consist  of  thromboses  in  the  placental  cotyledons  and  effused 
blood-clots,  variously  altered  and  decolorized  according  to  the  lapse  of 
time  since  separation  took  place.  Changes  occur  in  the  portion  of  the 
placenta  overlying  the  os  uteri  whether  separation  has  occurred  or  not. 
There  may  be  atrophy  of  the  placental  structure  in  this  situation,  as 
well  as  changes  of  form,  such  as  complete  or  partial  separation  into  two 
lobes,  the  junction  of  which  overlies  the  os  uteri.^ 

Natural  Tei^mination  when  the  Placenta  Presents. — The  history  of 
delivery,  if  left  to  nature,  is  specially  \vorthy  of  study,  as  guiding  to 
proper  rules  of  treatment.  It  sometimes  happens,  when  the  pains  are 
very  strong  and  the  delivery  rapid,  that  labor  is  completed  without  any 
hemorrhage  of  consequence.  "  Although,"  says  Cazeaux,  "  hemorrhage 
is  usually  considered  to  be  inevitable  under  such  circumstances,  yet  it 
may  not  appear  even  during  the  labor,  and  the  dilatation  of  the  os  uteri 
may  be  effected  without  the  loss  of  a  drop  of  blood."  Again,  Simpson 
conclusively  shoAved  that  when  the  placenta  was  expelled  before  the 
birth  of  the  child  all  hemorrhage  ceased. 

Barnes's  theory  of  placenta  pxevia,  which  has  been  pretty  generally 
adopted,  explains  satisfactorily  both  these  classes  of  cases.  He  describes  the 
uterine  cavity  as  divisible  into  three  zones  or  regions.  When  the  placenta 
is  situated  in  the  upper  or  middle  of  these  zones,  no  separation  or  hem- 
orrhage need  occur  during  labor.  When,  however,  it  is  situated  partially 
or  entirely  in  the  lower  or  cervical  zone,  the  expansion  of  the  cervix 
during  labor  must  produce  more  or  less  separation,  and  consequent  loss 
of  l)lood.  As  soon  as  the  previous  portion  of  the  placenta  is  sufficiently 
separated,  provided  contraction  of  the  uterine  tissue  be  present  to  seal 
up  the  mouths  of  the  vessels,  hemorrhage  no  longer  takes  place.  The 
placenta  may  not  be  entirely  detached,  but  no  further  hemorrhage  occurs, 
in  consequence  of  the  remaining  portion  being  engrafted  on  the  uterus 
beyond  the  region  of  unsafe  attachment.  In  the  former,  then,  of  these 
classes  of  cases  the  absence  of  hemorrhage  is  explained  on  this  theory  by 
the  pains  being  sufficiently  rapid  and  strong  to  complete  the  separation 
of  the  placental  attachment  from  the  lower  cervical  zone  before  flooding 
had  taken  place  ;  in  the  latter,  it  ceases,  not  necessarily  because  the  entire 
placenta  is  expeUed,  but  because  of  its  detachment  from  the  area  of  dan- 
gerous im[)]antation. 

Tlie  amount  of  cervical  expansion  required  for  this  purpose  varies  in 

different  cases.      Dr.  Duncan  ^  estimates  the  limit  of  the  spontaneous 

detaching  area  to  be  a  circle  of  4^  inches  diameter,  and  that  after  the 

cervix  has  expanded  to  that  extent  no  further  separation  or  hemorrhage 

'  Simelius,  Arch.  (jen.  de  Med.,  vol.  ii.,  1801.  "  Obst.  Trans.,  vol.  xv. 


406  LABOR. 

takes  place.  To  admit  of  the  passage  of  a  full-sized  head,  Barnes  esti- 
mates that  expansion  to  about  a  circle  of  6  inches  diameter  is  necessary ; 
on  the  other  hand,  he  has  sometimes  observed  "  that  the  hemorrhage  has 
completely  stopped  when  the  os  uteri  opened  to  the  size  of  the  rim  of  a 
wine-glass,  or  even  less." 

It  will  be  seen,  then,  that  in  this,  as  in  every  other  form  of  puerperal 
hemorrhage,  the  tendency  of  uterine  contraction  is  to  check  the  hemor- 
rhage, and  that,  provided  the  pains  are  sufficiently  energetic,  Nature  may 
be  capable  of  stopping  the  flooding  without  artificial  aid.  It  is  but 
rarely,  however,  that  she  can-  be  trusted  for  the  purpose ;  and  we  shall 
presently  see  that  these  theoretical  views  have  an  important  practical 
bearing  on  the  subject  of  treatment. 

Prognosis. — The  prognosis  to  both  the  mother  and  child  is  certainly 
grave  in  all  cases  of  placenta  prsevia.  Read,  in  his  treatise  on  placenta 
prsevia,  estimates  the  maternal  mortality,  from  the  statistics  of  a  large 
number  of  cases,  as  1  in  4^  cases,  and  Churchill  as  1  in  3.  This  is 
unquestionably  too  high  an  estimate,  and  based  on  statistics  the  accuracy 
of  which  cannot  be  relied  on.  The  mortality  will,  of  course,  greatly 
depend  on  the  treatment  adopted.  Doubtless,  if  cases  were  left  to  nature 
the  result  would  be  quite  as  unfavorable  as  Read  supposes.  But  if 
properly  managed  much  more  successful  results  may  be  safely  anticipated. 
Out  of  64  cases  recorded  by  Barnes,  the  deaths  were  6,  or  1  in  10|.  Under 
any  circumstances  the  risks  to  the  mother  are  very  great.  Churchill 
estimates  that  more  than  half  the  children  are  lost.  The  reasons  for  the 
great  danger  to  the  child  are  very  obvious,  subjected  as  it  is  to  the  risk 
of  asphyxia  from  the  loss  of  the  maternal  blood,  and  from  its  respira- 
tion being  carried  on  during  labor  by  a  placenta  which  is  only  partially 
attached ;  many  children  also  perish  from  prematurity  or  from  mal- 
presentation. 

Treatment. — Whenever,  in  the  latter  months  of  pregnancy,  a  sudden 
hemorrhage  occurs,  the  possibility  of  placenta  prsevia  will  naturally  sug- 
gest itself,  and  by  a  careful  vaginal  examination — which  nnder  such 
circumstances  should  always  be  insisted  on — the  existence  of  this  com- 
plication ^^'ill  generally  be  readily  ascertained.  It  is  seldom  that  the  os 
is  not  sufficiently  dilated  to  enable  us  to  satisfy  ourselves  whether  the 
placenta  is  presenting. 

Is  it  Justifiable  to  Alloto  the  Pregnancy  to  Continue  f — The  first  ques- 
tion that  will  arise  is.  Are  we  justified  in  temporizing,  using  means  to 
check  the  hemorrhage,  and  allowing  the  pregnancy  to  continue?  This 
Is  the  course  which  has  generally  been  recommended  in  works  on  mid- 
wifery. We  are  told  to  place  the  patient  on  a  hard  mattress,  not  to  heat 
or  overburden  her  with  clothes,  to  keep  her  absolutely  at  rest,  to  have 
the  room  cooled  and  well  aired,  to  apply  cold  cloths  to  the  vulva  and 
lower  part  of  the  abdomen,  to  administer  cold  and  acidulated  drinks  in 
abundance,  and  to  prescribe  acetate  of  lead  and  opium,  or  gallic  acid,  on 
account  of  their  supposed  haemostatic  effect.  Of  late  years  the  judicious- 
ness of  these  recommendations  has  been  strongly  contested.  Not  long 
ago  an  interesting  discussion  took  place  at  the  Obstetrical  Society  of 
London  ^  on  a  paper  in  which  Dr.  Greenhalgh  advised  the  immediate 

1  Obst.  Trans.,  vol.  vi.  p.  188. 


HEMORRHAGE  BEFORE  DELIVERY.  407 

induction  of  labor  in  all  cases  of  placenta  prsevia,  No  less  than  six 
metropolitan  teachers  of  midwifery  took  part  in  it,  and,  although  they 
differed  in  details,  they  all  agreed  as  to  the  unadvisability  of  allowing 
pregnancy  to  progress  when  the  existence  of  placenta  prsevia  had  been 
distinctly  ascertained.  The  reasons  for  this  course  are  obvious  and 
unanswerable.  The  tabor,  indeed,  very  often  comes  on  of  its  own  accord, 
but  should  it  not  do  so  the  patient's  life  must  be  considered  to  be  always 
in  jeopardy  until  the  case  is  terminated,  for  no  one  can  be  sure  that  most 
dangerous,  or  even  fatal,  flooding  may  not  at  any  moment  come  on  ;  and 
the  nearer  to  term  the  patient  is,  the  greater  the  risk  to  which  slie  is 
subjected.  Nor  is  the  safety  of  the  child  likely  to  be  increased  by  delay. 
Provided  it  has  arrived  at  a  viable  age,  the  chances  of  its  being  born 
alive  may  be  said  to  be  greater  if  pregnancy  be  terminated  at  once  than 
if  repeated  floodings  occur.  I  think,  therefore,  that  it  may  be  safely 
laid  down  as  an  axiom  that  no  attempt  should  be  made  to  prevent  the 
termination  of  pregnancy,  but  that  our  treatment  should  rather  contem- 
plate its  conclusion  as  soon  as  possible.  An  exception  may,  however,  be 
made  to  this  rule  when  the  hemorrhage  occurs  for  the  first  time  before 
the  seventh  month  of  utero-gestation.  The  chances  of  the  child  sur- 
viving would  then  be  very  small,  and  if  the  hemorrhage  be  not  alarm- 
ing, as  at  that  early  period  is  likely  to  be  the  case,  the  measures  indicated 
above  may  be  employed  in  the  hope  of  carrying  on  the  pregnancy  until 
there  is  a  prospect  of  the  patient  being  delivered  of  a  living  child.  But 
little  benefit  is  likely  to  accrue  from  astringent  drugs.  Perfect  rest  in 
bed  is  more  likely  to  be  beneficial  than  anything  else,  and  astringent 
vaginal  pessaries  of  matico  or  perchloride  of  iron  might  be  used  with 
advantage  as  local  hsemostatics. 

Various  Methods  of  Treatment. — When  the  period  of  pregnancy  or 
the  urgency  of  the  case  determines  us  to  forego  any  attempt  at  temporiz- 
ing, there  are  various  plans  of  treatment  to  be  considered.  These  are, 
chiefly:  1.  Puncture  of  the  membranes ;  2.  Plugging  of  the  vagina ;  3. 
Turning ;  4.  Partial  or  complete  separation  of  the  placenta.  It  will  be 
well  to  consider  in  detail  the  relative  advantages  of,  and  indications  for, 
each  of  these.  It  is  seldom,  however,  that  we  can  trust  to  any  one  per 
se ;  in  most  cases  two  or  more  are  required  to  be  used  in  combination. 

1.  Puncture  of  the  membranes  is  recommended  by  Barnes  as  the  first 
measure  to  be  adopted  in  all  cases  of  placenta  prsevia  sufficient  to  cause 
anxiety.  "It  is,"  he  says,  "the  most  generally  efficacious  remedy,  and 
it  can  always  be  applied."  The  primary  object  gained  is  the  increase  of 
uterine  contraction  Ijy  the  evacuation  of  the  liquor  amnii.  Although 
the  first  effect  of  this  may  be  to  increase  the  flow  of  blood  by  further 
separation  of  the  placenta,  the  flooding  can  generally  be  commanded  by 
])lugging  until  the  os  is  sufficiently  dilated  to  permit  the  passage  of  the 
child.  As  a  rule,  tlierc  is  no  great  difficulty  in  effecting  the  puncture, 
es])ecially  if  the  ])lacental  j)rcsentation  be  only  partial.  A  quill  or  other 
suitable  contrivance,  guided  by  the  exauiining  finger,  is  passed  tlu'ough 
the  cervix  and  pushed  through  tlie  membranes.  In  com])letc  ])lacenta 
pnevia  it  may  not  l)e  so  easy  to  effect  the  evacuation  of  the  liquor  amnii  ; 
and,  althougli  many  authorities  advise  the  penetration  of  the  substance 
of  the  ])lacenta  itself,  I  am  inclined  to  think  that  it  would  be  better  to 


408  LABOR. 

abandon  the  attempt  in  such  cases  and  trust  to  other  methods  of  treat- 
ment. 

The  objections  whicli  have  been  raised  to  puncture  of  the  membranes 
are  chiefly  that  it  interferes  with  the  gradual  dilatation  of  the  os  and 
renders  the  operation  of  turning  much  more  difficult.  The  os  is  not, 
however,  so  regularly  dilated  by  the  bag  of  memhranes  in  cases  of  pla- 
centa prsevia  as  it  is  in  ordinary  labors.  Moreover,  as  the  cervical  tis- 
sues are  generally  relaxed  by  the  hemorrhage,  the  dilatation  is  easily 
effected.  Should  we  desire  to  dilate  the  os  preparatory  to  turning,  we 
can  readily  do  so  by  means  of  Barnes's  bags,  which  act  at  the  same  time 
as  an  efficient  plug.  The  objections,  therefore,  are  not  so  weighty  as  they 
might  have  been  before  these  artificial  dilators  were  used.  I  am  inclined 
for  these  reasons  to  agree  with  the  recommendation  that  puncture  of  the 
membranes  should  be  resorted  to  in  all  cases  of  placenta  prsevia. 

2.  Plugging  of  the  vagina — or,  still  better,  of  the  cavity  of  the  cervix 
itself — is  especially  serviceable  in  cases  in  which  the  os  is  not  sufficiently 
dilated  to  admit  of  turning  or  of  separation  of  the  placenta,  and  in 
which  the  hemorrhage  still  continues  after  the  evacuation  of  the  liquor 
amnii.  By  means  of  this  contrivance  the  escape  of  blood  is  effectually 
controlled. 

The  best  way  of  plugging  is  to  introduce  a  sponge  tent  of  sufficient 
size  into  the  cervical  canal,  and  to  keep  it  in  situ  by  a  vaginal  plug ;  the 
best  material  for  the  latter  and  the  method  of  introduction  are  described 
under  the  head  of  Abortion.  The  sponge  tent  not  only  controls  the 
hemorrhage  more  effectually  than  any  other  means,  but  is  at  the  same 
time  effecting  dilatation  of  the  cervix.  It  cannot  be  left  in  many  hours, 
on  account  of  the  irritation  produced  and  of  the  fetor  from  accumulating 
vaginal  discharges.  As  long  as  it  is  in  position  we  should  carefully 
examine,  from  time  to  time,  to  see  that  no  blood  is  oozing  past  it.  If 
preferred,  a  Barnes's  bag  may  be  used  for  the  same  purpose. 

While  the  plug  is  in  situ  other  modes  of  exciting  uterine  action  may 
be  very  advantageously  employed,  such  as  a  firm  abdominal  bandage, 
occasional  friction  over  the  uterus,  and  repeated  doses  of  ergot.  The  last 
is  specially  recommended  by  Dr.  Greenhalgh,  who  used  at  the  same  time 
a  plug  formed  of  an  oblong  india-rubber  ball  inflated  with  air  and 
covered  with  spongio-piline. 

On  the  removal  of  the  plug  we  may  find  that  considerable  dilatation 
has  taken  place,  perhaps  to  a  sufficient  extent  to  admit  of  labor  being 
safely  concluded  by  the  natural  efforts.  In  that  case  we  shall  find  that, 
although  the  pains  continue,  no  fresh  hemorrhage  occurs.  Should  it  do 
so,  it  ^vill  be  necessary  to  adopt  further  measures. 

3.  Turning  has  long  been  considered  the  remedy  j9«r  excellence  in  pla- 
centa prsevia  ;  and  it  is  of  unquestionable  value  in  suitable  cases.  INIuch 
harm,  however,  has  been  done  when  it  has  been  practised  before  the  os 
was  sufficiently  dilated  to  admit  of  the  passage  of  the  hand,  or  when  the 
patient  was  so  exhausted  by  previous  hemorrhage  as  to  be  unable  to  bear 
the  shock  of  the  operation.  The  records  of  many  fatal  cases  in  the 
practice  of  those  who  taught,  as  did  the  large  majority  of  the  older 
writers,  that  turning  at  all  risks  was  essential  conclusively  prove  this 
assertion. 


HEMORRHAGE  BEFORE  DELIVERY.  409 

It  is  most  likely  to  prove  serviceable  when,  either  at  first  or  after  the 
use  of  the  tampon,  the  os  is  sufficiently  dilated  to  admit  the  hand,  and 
when  the  strength  of  the  patient  is  not  much  enfeebled.  If  she  have  a 
small,  feeble,  and  thready  jjulse,  it  is  certainly  inapplicable,  unless  all 
other  methods  of  arresting  the  hemorrhage  have  failed.  And  even  then 
it  would  be  well  to  attempt  to  rally  the  jaatient  from  her  exhausted  state 
by  stimulants,  etc.  before  the  operation  is  commenced. 

Provided  the  placental  presentation  be  partial,  the  operation  can  be 
performed  without  difficulty  in  the  usual  way.  In  central  implantation 
the  passage  of  the  hand  may  give  rise  to  some  difficulty.  Dr.  Rigby 
recommends  that  it  should  be  pushed  through  the  substance  of  the  pla- 
centa until  it  reaches  the  uterine  cavity.  It  is  hardly  possible  to  conceive 
how  this  could  be  done  without  completely  detaching  the  placenta,  and 
still  less  to  understand  how  the  foetus  could  be  dragged  through  the 
aperture  thus  made.  It  will  be  far  better  to  pass  the  hand  by  the  border 
of  the  placenta,  separating  it  as  we  do  so;  and,  if  we  can  ascertain  to 
which  side  of  the  cervix  it  is  least  attached,  that  should  be  chosen  for 
the  purpose.  In  all  cases  in  which  it  is  possible  turning  by  the  bi-polar 
method  should  be  preferred.  In  cases  of  placenta  praevia  especially  it 
offers  many  advantages.  The  operation  can  be  soon  performed,  complete 
dilatation  of  the  os  is  not  so  necessary,  and  it  involves  less  bruising 
of  the  cervix,  which  is  likely  to  be  specially  dangerous.  When  once  a 
foot  has  been  brought  within  the  os,  the  delivery  need  not  be  hurried. 
The  foot  forms  a  plug  which  effectually  prevents  all  further  loss,  and  we 
may  then  safely  wait  until  we  can  excite  uterine  contraction  and  termi- 
nate the  labor  with  safety.  Fortunately,  the  relaxation  of  the  uterus 
which  is  so  often  present  facilitates  this  manner  of  performing  version, 
and  it  can  generally  be  successfully  accomplished.  Should  the  case  be 
one  which  is  otherwise  suitable  for  turning,  and  the  requisite  amount  of 
dilatation  of  the  cervix  not  be  present,  the  latter  can  generally  be 
effected  in  the  space  of  an  hour  or  more  (while  at  the  same  time  a 
further  loss  of  blood  is  effectually  prevented)  by  the  use  of  Barnes's  bags. 

4.  Entire  separation  of  the  placenta  was  originally  recommended  by 
Simpson  in  his  well-known  paper  on  the  subject.  The  reasons  which 
induced  him  to  recommend  it  have  already  been  stated.  It  is  a  mistake 
to  suppose,  however,  as  is  so  often  done,  that  he  intended  to  recommend 
it  in  all  cases  alike.  This  supposition  he  was  always  careful  to  deny. 
He  advised  it  especially^ — 

1.  When  the  child  is  dead. 

2.  When  the  child  is  not  yet  viable. 

3.  When  the  hemorrhage  is  great  and  the  os  uteri  is  not  yet  sufficiently 
dilated  for  safe  turning.    This  was  the  state  in  11  out  of  39  cases  (Lee). 

4.  When  the  pelvic  passages  are  too  small  for  safe  and  easy  turning. 

5.  When  the  mother  is  too  exhausted  to  bear  turning. 

6.  When  the  evacuation  of  the  liquor  amnii  fails. 

7.  When  the  uterus  is  too  firmly  contracted  fi)r  turning.^ 

These  are  very  much  the  cases  in  ^vhich  all  modern  accoucheurs  would 
exclude  the  operation  of  turning;  and  it  was  especially  when  that  was 
unsuitable  that  Simpson  advised  extraction   of  the  placenta.     As   his 

'  Selected  Ohd.  Fbr/w,  p.  G8. 


410  LABOR. 

theory  of  the  source  of  hemorrhage  i.-?  now  ahnost  universally  disbelieved, 
so  has  the  practice  based  on  it  fallen  into  disuse,  and  it  need  not  be  dis- 
cussed at  length.  It  is  very  doubtful  whether  the  complete  separation 
and  extraction  of  the  placenta  was  a  feasible  operation ;  unquestionably, 
it  can  be  by  no  means  so  easy  as  Simpson's  Avritings  would  lead  us  to 
suppose.  The  introduction  of  the  hand  far  enough  to  remove  the  pla- 
centa in  an  exhausted  patient  would  probably  cause  as  much  shock  as 
the  operation  of  turning  itself;  and  another  very  formidable  objection 
to  the  procedure  is  the  almost  certain  death  of  the  child  if  any  time 
elapse  between  the  separation  of  the  placenta  and  the  completion  of 
delivery.  The  modification  of  this  method  so  strongly  advocated  by 
Barnes  is  certainly  much  easier  of  application,  and  would  appear  to 
answer  every  purpose  that  Simpson's  operation  eifected.  It  is  impossible 
to  describe  it  better  than  in  Barnes's  own  words  :  ^ 

"  The  operation  is  this :  Pass  one  or  two  fingers  as  far  as  they  will  go 
through  the  os  uteri,  the  hand  being  passed  into  the  vagina  if  necessary ; 
feeling  the  placenta,  insinuate  the  finger  between  it  and  the  uterine  wall ; 
sweep  the  finger  round  in  a  circle  so  as  to  sejjarate  the  placenta  as  far  as 
the  finger  can  reach:  if  you  feel  the  edge  of  the  placenta  where  the 
membranes  begin,  tear  open  the  membranes  carefully,  especially  if  these 
have  not  been  previously  ruptured ;  ascertain,  if  you  can,  what  is  the 
presentation  of  the  child  before  withdrawing  your  hand.  Commonly, 
some  amount  of  retraction  of  the  cervix  takes  place  after  the  operation, 
and  oflen  the  hemorrhage  ceases." 

It  will  be  seen,  from  w^hat  has  been  said,  that  no  one  rule  of  practice 
can  be  definitely  laid  down  for  all  cases  of  placenta  prsevia.  Our  treat- 
ment in  each  individual  case  must  be  guided  by  the  particular  conditions 
that  are  present ;  and  if  only  we  bear  in  mind  the  natural  history  of  the 
hemorrhage,  we  may  confidently  look  to  a  favorable  termination. 

Summary  of  Bides  for  Treatment. — It  may  be  useful,  in  conclusion,  to 
recapitulate  the  rules  which  have  been  laid  down  for  treatment  in  the 
form  of  a  series  of  propositions: 

I.  Before  the  child  has  reached  a  viable  age  temporize,  provided  the 
hemorrhage  be  not  excessive,  until  pregnancy  has  advanced  sufficiently 
to  afford  a  reasonable  hope  of  saving  the  child.  For  this  purpose  the 
chief  indication  is  absolute  rest  in  bed,  to  which  other  accessory  means 
of  preventing  hemorrhage,  such  as  cold,  astringent  pessaries,  etc.,  may  be 
added. 

II.  In  hemorrhage  occurring  after  the  seventh  month  of  utero-gesta- 
tion  no  attempt  should  be  made  to  prolong  the  pregnancy. 

III.  In  all  cases  in  which  it  can  be  easily  effected  the  membranes 
should  be  ruptured.  By  this  means  uterine  contractions  are  favored  and 
the  bleeding  vessels  compressed. 

IV.  If  the  hemorrhage  be  stopped,  the  case  may  be  left  to  nature. 
If  flooding  continue,  ancl  the  os  be  not  sufficiently  dilated  to  admit  of 
the  labor  being  readily  terminated  by  turning,  the  os  and  the  vagina 
should  be  carefully  plugged,  while  uterine  contractions  are  promoted  by 
abdominal  bandages,  uterine  compression,  and  ergot.  The  plug  must 
not  be  left  in  beyond  a  few  hours. 

^  Obstet.  Operalionx,  2d  ed.,  p.  417. 


HEMORRHAGE  BEFORE  DELIVERY.  411 

V.  If,  on  removal  of  the  plug,  the  os  be  sufficiently  expanded  and 
the  general  condition  of  the  patient  be  good,  the  labor  may  be  terminated 
by  turning,  the  bi-polar  method  being  used  if  possible.  If  the  os  be  not 
oj^en  enough,  it  may  be  advantageously  dilated  by  a  Barnes's  bag,  which 
also  acts  as  a  j)lug. 

VI.  Instead  of,  or  before  resorting  to,  turning  the  placenta  may  be 
separated  around  the  site  of  its  attachment  to  the  cervix.  This  practice 
is  specially  to  be  preferred  when  the  patient  is  much  exhausted  and  in  a 
condition  unfavorable  for  bearing  the  shock  of  turning. 

\_Dr.  J.  Braxton  Hicks'  bi-manual  method  of  turning^  as  tested  in 
Berlin  by  Drs.  Hofmeier,  Behm,  and  Lomer,  promises  much  better 
results  than  any  other  method  of  treatment  in  cases  of  placenta  preevia. 
According  to  Dr.  Lomer's  report  in  the  Am.  Journ,  of  Obstetrics  for 
December,  1884,  Dr.  Hofmeier  operated  upon  37  cases,  and  saved  36 
women  and  ,14  children ;  Dr.  Behm,  upon  40  cases,  all  saved,  but  lost 
31  children ;  and  he  liimself,  with  eight  other  assistants,  upon  101  cases, 
saving  94,  with  50  children.  This  gives  8  deaths  of  women  and  105 
of  children  in  178  cases,  or  a  mortality  of  4|-  per  cent,  of  the  former 
and  60  per  cent,  of  the  latter.  Dr.  Lomer's  directions  are  as  follows : 
"  Turn  by  the  bi-manual  method  as  soon  as  possible ;  pull  down  the  leg, 
and  tampon  with  it  and  with  the  breech  of  the  child  the  ruptured  vessels 
of  the  placenta.  Do  not  extract  the  child  then :  let  it  come  by  itself,  or 
at  least  only  assist  its  natural  expulsion  by  gentle  and  rare  tractions.  Do 
away  with  the  plug  as  much  as  possible ;  it  is  a  dangerous  thing,  for  it 
favors  infection  and  valuable  time  is  lost  with  its  application.  Do  not 
wait  in  order  to  perform  turning  until  the  cervix  and  the  os  are  suf- 
ficiently dilated  to  allow  the  hand  to  pass.  Turn  as  soon  as  you  can 
pass  one  or  two  fingers  through  the  cervix.  It  is  unnecessary  to  force 
your  fingers  through  the  cervix  for  this.  Introduce  the  whole  hand  into 
the  vagina,  pass  one  or  two  fingers  through  the  cervix,  rupture  the  mem- 
branes, and  turn  by  Braxton  Hicks'  bi-manual  method."  .  ..."  If  the 
placenta  is  in  your  way,  try  to  rupture  the  membranes  at  its  margin ;  but 
if  this  is  not  feasible,  do  not  lose  time:  perforate  the  placenta  with  your 
finger ;  get  hold  of  a  leg  as  soon  as  possible,  and  bring  it  down." — JEd.] 


CHAPTER   Xiy. 


HEMORRHAGE  FROM  SEPARATION  OF  A  NORMALLY-SITUATED 

PLACENTA. 

Definition. — This  is  tlie  form  of  hemorrhage  which  is  generally  de- 
scribed in  obstetric  works  as  "  accidental,"  in  contradistinction  to  the 
'^unavoidable"  hemorrhage  of  placenta  prtevia.   In  discussing  the  latter 
we  have  seen  that  tlie  term  "accidental"  is  one  that  is  aj)t  to  mislead, 
['  Lancet,  July,  1860;  Obsklrical  Transactions,  vol.  v.  i).  222.] 


412  LABOR. 

and  that  the  causation  of  the  hemorrhage  in  placenta  prsevia  is,  in  some 
cases  at  least,  closely  allied  to  that  of  the  variety  of  hemorrhage  we  are 
now  considering. 

When,  from  any  cause,  separation  of  a  normally-situated  placenta 
occurs  before  delivery,  more  or  less  blood  is  necessarily  effused  from 
the  ruptured  utero-placental  vessels,  and  the  subsequent  course  of  the 
case  may  be  twofold  :  1.  The  blood,  or  at  least  some  part  of  it,  may 
find  its  way  between  the  membranes  and  the  decidua,  and  escape  from 
the  OS  uteri.  This  constitutes  the  typical  "  accidental  "  hemorrhage  of 
authors.  2.  The  blood  may  fail  to  find  a  passage  externally,  and  may 
collect  internally,  giving  rise  to  very  serious  symptoms,  and  even  proving 
fatal,  before  the  true  nature  of  the  case  is  recognized.  Cases  of  this 
kind  are  by  no  means  so  rare  as  the  small  amount  of  attention  paid  to 
them  by  authors  might  lead  us  to  suppose ;  and  from  the  obscurity  of 
the  symptoms  and  difficulty  of  diagnosis  they  merit  special  study.  Dr. 
GoodelP  has  collected  together  no  less  than  106  instances  in  which  this 
complication  occurred. 

Causes  and  Pathology. — The  causes  of  placental  separation  may  be 
very  various.  In  a  large  number  of  cases  it  has  followed  an  accident 
or  exertion  (such  as  slipping  down  stairs,  stretching,  lifting  heavy  weights, 
and  the  like)  which  has  probably  had  the  effect  of  lacerating  some  of 
the  placental  attachments.  At  other  times  it  has  occurred  without  such 
appreciable  cause,  and  then  it  has  been  referred  to  some  change  in  the 
uterus,  such  as  a  more  than  usually  strong  contraction  producing  sepa- 
ration, or  some  accidental  determination  of  blood  causing  a  slight  ex- 
travasation between  the  placenta  and  the  uterine  wall,  the  irritation  of 
which  leads  to  contraction  and  further  detachment.  Causes  such  as 
these,  which  are  of  frequent  occurrence,  will  not  produce  detachment 
except  in  women  otherwise  predisposed  to  it.  It  generally  is  met  with 
in  women  who  have  borne  many  children,  more  especially  in  those  of 
Aveakly  constitution  and  impaired  health,  and  rarely  in  primiparse.  Cer- 
tain constitutional  states  probably  predispose  to  it,  such  as  albuminuria 
or  exaggerated  ansemia,  and,  still  more  so,  degenerations  and  diseases  of 
the  placenta  itself. 

This  form  of  hemorrhage  rarely  occurs  to  an  alarming  extent  until 
the  latter  months  of  pregnancy,  often  not  until  labor  has  commenced. 
The  great  size  of  the  placental  vessels  in  advanced  pregnancy  affords  a 
reasonable  explanation  of  this  fact. 

Symptoms  and  Diagnosis. — If,  after  separation  of  a  portion  of  the 
placenta,  the  blood  finds  its  way  between  the  membranes  and  the  decidua, 
its  escape  per  vaginam,  even  although  in  small  amount,  at  once  attracts 
attention  and  reveals  the  nature  of  the  accident.  It  is  otherwise  when 
we  have  to  do  with  a  case  of  concealed  hemorrhage,  the  diagnosis  of 
which  is  often  a  matter  of  difficulty.  Then  the  blood  probably  at  first 
collects  between  the  uterus  and  the  placenta.  Sometimes  marginal  sepa- 
ration does  not  occur,  and  large  blood-clots  are  formed  in  this  situation 
and  retained  there.  More  often  the  margin  of  the  placenta  separates 
and  the  blood  collects  between  the  membranes  and  the  uterine  wall, 
either  toward  the  cervix,  where  the  presenting  part  of  the  child  may 

^  Amer.  Journ.  of  Obst.,  vol.  ii. 


BEMOBBHAGE  BEFOBE  DELIVEBY.  413 

prevent  its  escape,  or  near  the  fundus.  In  the  latter  case  especially  the 
coagula  are  .apt  to  cause  very  painful  stretching  and  distension  of  the 
uterus.  The  blood  may  also  find  its  way  into  the  amniotic  cavity,  but 
more  frequently  it  does  not  do  so — probably,  as  Goodell  has  pointed  out, 
because,  "  should  the  os  uteri  be  closed,  the  membranes,  however  deli- 
cate, cannot,  other  things  being  equal,  rupture  any  sooner  from  the  ute- 
rine walls,  for  the  sum  of  the  resistance  of  the  enclosed  liquor  amnii, 
being  equally  distributed,  exactly  counterbalances  the  sum  of  the  pres- 
sure exerted  by  the  effusion."  This  point  is  of  some  practical  import- 
ance, because,  after  rupture  of  the  membranes,  the  liquor  amnii  is  fre- 
quently found  untinged  with  blood ;  and  this  might  lead  us  to  suppose 
ourselves  mistaken  in  our  diagnosis  if  this  fact  were  not  borne  in  mind. 

Symptoms  of  Concealed  Accidental  Hemorrhage. — The  most  jjromi- 
nent  symptoms  in  concealed  internal  hemorrhage  are  extreme  collapse 
and  exhaustion,  for  which  no  adequate  cause  can  be  assigned.  These 
differ  from  those  of  ordinary  syncope,  with  which  they  might  be  con- 
founded, chiefly  in  their  persistence  and  severity,  and  in  the  presence  of 
the  symptoms  attending  severe  loss  of  blood,  such  as  coldness  and  pallor 
of  the  surface,  great  restlessness  and  anxiety,  rapid  and  sighing  respira- 
tion, yawning,  feeble,  quick,  and  compressible  pulse.  When  there  is 
severe  internal,  with  slight  external,  hemorrhage,  we  may  be  led  to  a 
proper  diagnosis  by  observing  that  the  constitutional  symptoms  are  much 
more  severe  than  the  amount  of  external  hemorrhage  -would  account  for. 
UterinejDain  is  generally  present,  of  a  tearing  and  stretching  character,  I 
sometimes  moderate  in  amount,  more  often  severe,  and  occasionally 
amounting  to  intolerable  anguish.  It  is  often  localized,  and  doubtless  \ 
depends  on  the  distension  of  the  uterus  by  the  retained  coagula.  If  the  ^ 
distension  be  marked,  there  may  be  an  irregularity  in  the  form  of  the 
uterus  at  the  site  of  sanguineous  effusion ;  but  this  will  be  difficult  to 
make  out,  except  in  women  with  thin  and  unusually  lax  abdominal 
parietes,  A  rapid  increase  in  the  size  of  the  uterus  has  been  described 
as  a  sign  by  Cazeaux  and  others.  It  is  not  very  likely  that  this  will  be 
appreciable  toward  the  end  of  utero-gestation,  as  a  very  large  amount  of 
effusion  would  be  necessary  to  produce  it.  At  an  earlier  period  of  preg- 
nancy, at  or  about  the  fifth  month,  I  made  it  out  very  distinctly  in  a 
case  in  my  own  practice.  It  obviously  must  have  occurred  to  an  enor- 
mous extent  in  a  case  related  by  Chevalier,  in  which  post-mortem  Csesa- 
rean  section  was  performed  under  the  impression  that  the  pregnancy  had 
advanced  to  term,  but  only  a  three  months'  foetus  was  found,  imbedded 
in  coagula  which  distended  the  uterus  to  the  size  of  a  nine  months'  ges- 
tation,' Labor-pains  may  be  entirely  absent.  If  present,  they  are  gen- 
erally feeble,  irregular,  and  inefficient. 

Differential  JDiar/nosis. — The  only  condition,  besides  ordinary  syncope, 
likely  to  be  confounded  witli  this  form  of  hemorrhage  is  rupture  of  the 
uterus,  to  whicli  the  intense  pain  and  profound  collajjse  induce  consider- 
able resemblance.  The  latter  rarely  occurs  until  after  labor  has  been  ' 
some  time  in  progress  and  after  the  escaj^e  of  the  liquor  amnii ;  whereas  ! 
liemon-hage  usually  occurs  either  before  lalx)r  has  commenced  or  at  an 
early  stage.     The  recession  of  the  presentation  and  the  escape  of  the 

^  Journ.  de  Med.  din.  et  pharmac,  vol.  xxi.  p.  303. 


414  LABOR. 

foetus  into  the  abdominal  cavity  in  cases  of  rupture  will  further  aid  in 
establishing  the  diagnosis. 

Prognosis. — The  prognosis,  when  blood  escapes  externally,  is,  on  the 
whole,  not  unfavorable.  The  nature  of  the  case  is  apparent,  and  reme- 
dial measures  are  generally  adopted  sufficiently  early  to  prevent  serious 
mischief.  It  is  different  with  the  concealed  form,  in  which  the  mortality 
is  very  great.  Out  of  Goodell's  106  cases,  no  less  than  54  mothers  died. 
This  excessive  death-rate  is  no  doubt  partly  due  to  the  fact  that  extreme 
prostration  so  often  occurs  before  the  existence  of  hemorrhage  is  sus- 
pected, and  partly  to  the  accident  generally  happening  in  women  of 
weakly  and  diseased  constitution.  The  prognosis  to  the  child  is  still 
more  grave.  Out  of  107  children,  only  6  were  born  alive.  The 
almost  certain  death  of  the  child  may  be  explained  by  the  fact  that 
Avhen  blood  collects  between  the  uterus  and  the  placenta  the  fcetal  por- 
tion of  the  latter  is  probably  lacerated,  and  the  child  then  also  dies  from 
hemorrhage. 

Treatment. — In  this,  as  in  all  other  forms  of  puerperal  hemorrhage, 
-  the  great  hsemostatic  is  uterine  contraction,  and  that  we  must  try  to 
,  encourage  by  all  possible  means.  The  first  thing  to  be  done,  whether 
j  the  hemorrhage  be  apparent  or  concealed,  is  to  rupture  the  membranes. 
i  If  the  loss  of  blood  be  only  slight,  this  may  suffice  to  control  it,  and 
the  case  may  then  be  left  to  "nature.  A  firm  abdominal  binder  should, 
however,  be  apj^lied  to  prevent  any  risk  of  blood  collecting  internally, 
as  there  is  nothing  to  prevent  its  filling  the  uterine  cavity  after  the  mem- 
branes are  ruptured.  Contraction  may  be  further  advantageously  solic- 
ited by  uterine  compression  and  by  the  administration  of  full  doses  of 
ergot.  If  hemorrhage  continue,  or  if  we  have  any  reason  to  suspect 
concealed  hemorrhage,  the  sooner  the  uterus  is  emptied  the  better.  If 
the  OS  be  sufficiently  dilated,  the  best  practice  will  be  to  turn  without 
further  delay,  using  the  bi-polar  method  if  possible.  If  the  os  be  not 
open  enough,  a  Barnes's  bag  should  be  introduced,  while  firm  pres- 
sure is  kept  up  to  prevent  uterine  accumulation.  Should  the  collapsed 
condition  of  the  patient  be  very  marked,  the  mere  shock  of  the  opera- 
tion might  turn  the  scale  against  her.  Under  such  circumstances  it  may 
be  better  practice  to  delay  further  procedure  until,  by  the  administration 
of  stimulants,  warmth,  etc.,  we  have  succeeded  in  producing  some  amount 
of  reaction,  keeping  up,  in  the  mean  while,  firm  pressure  on  the  uterus. 
Should  the  head  be  low  down  in  the  pelvis,  it  may  be  easier  to  complete 
labor  by  means  of  the  forceps. 


HEMOBRHAGE  AFTER  DELIVERY.  415 


CHAPTER   Xy. 

HEMOKKHAGE  AFTEK  DELIVEKY. 

lis  Importance. — Hemorrhage  during  or  shortly  after  the  third  stage 
of  labor  is  one  of  the  most  trying  and  dangerous  accidents  connect- 
ed with  parturition.  Its  sudden  and  unexpected  occurrence  just  after 
the  labor  appears  to  be  happily  terminated,  and  its  alarming  effect 
on  the  patient,  who  is  often  placed  in  the  utmost  danger  in  a  few 
moments,  tax  the  presence  of  mind  and  the  resources  of  the  practitioner 
to  the  utmost,  and  render  it  an  imperative  duty  on  every  one  who  prac- 
tises midwifery  to  make  himself  thoroughly  acquainted  with  its  causes 
and  preventive  and  curative  treatment.  There  is  no  emergency  in  obstet- 
rics which  leaves  less  time  for  reflection  and  consultation,-  and  the  life  of 
the  patient  will  often  depend  on  the  prompt  and  immediate  action  of  the 
medical  attendant. 

Frequency  of  Post-partum  Hemorrhage. — Post-partum  hemorrhage  is 
one  of  the  most  frequent  complications  of  delivery.  I  clo  not  know  of 
any  statistics  which  enable  us  to  judge  with  accuracy  of  its  frequency, 
but  I  believe  it  to  be  an  unquestionable  fact  that,  especially  in  the  upper 
ranks  of  society,  it  is  very  common  indeed.  This  is  probably  due  to  the 
effects  of  civilization  ancl  to  the  mode  of  life  of  patients  of  that  class, 
whose  whole  surroundings  tend  to  produce  a  lax  habit  of  body  which 
favors  uterine  inertia,  the  principal  cause  of  post-partum  hemorrhage. 
In  the  report  of  the  Registrar-General  for  the  five  years  from  1872  to 
1876,  3524  deaths  are  attributed  to  flooding.  The  majority  of  these 
must  have  been  caused  by  post-partum  hemorrhage,  although  some  may 
have  been  from  other  forms. 

Generally  a  Preventable  Accident. — Fortunately,  it  is,  to  a  great 
extent,  a  preventable  accident.  I  believe  this  fact  cannot  be  too  strongly 
impressed  on  the  practitioner.  If  the  third  stage  of  labor  be  properly 
conducted,  if  every  case  be  treated — as  every  case  ought  to  be — as  if 
hemorrhage  were  impending,  it  would  be  much  more  infrequent  than  it 
is.  It  is  a  curious  fact  that  post-partum  hemorrhage  is  much  more 
common  in  the  practice  of  some  medical  men  than  in  that  of  others,  the 
reason  being  that  those  who  meet  with  it  often  are  careless  in  their  man- 
agement of  their  patients  immediately  after  the  birth  of  the  child.  That 
is  just  the  time  when  the  assistance  of  a  properly-qualified  practitioner 
is  of  value — much  more  so  than  before  the  second  stage  of  labor  is  con- 
cluded ;  hence,  when  I  hear  that  a  medical  man  is  coustantly  meeting 
witli  severe  post-i)artum  hemorrhage,  I  hold  myself  justified,  ipso  facto, 
in  inferring  that  he  does  not  know  or  does  not  practise  the  proper  mode 
of  managing  the  third  stage  of  labor. 

Causes  and  Naturd's  Method  of  Controlling  Hemorrhage  (ffer  Delivery. 
— Tin;  ])];iceiita,  as  we  have  seen,  is  separated  by  tlie  last  ])ains,  and  the 
blood,  which   in  greater  or  less  quantity  accompanies  the  fetus,  prob- 


416  .  LABOR. 

ably  comes  from  tlie  iitero-placental  vessels  which  are  then  lacerated. 
Almost  immediately  afterward  the  uterus  contracts  firmly,  and  in  a 
typical  labor  assumes  the  hard  cricket-ball  form  which  is  so  comforting 
to  the  accoucheur  to  feel.  The  result  is  the  compression  of  all  the  vas- 
cular trunks  which  ramify  in  its  walls,  both  arteries  and  veins,  and  thus 
the  flow  of  blood  though  them  is  prevented.  By  referring  to  what  has 
been  said  as  to  the  anatomy  of  the  muscular  fibres  of  the  gravid  uterus, 
especially  at  the  placental  site  (p.  65),  it  will  be  seen  how  admirably  they 
are  adapted  for  this  purpose.  The  arrangement  of  the  vessels  themselves 
favors  the  haemostatic  action  of  uterine  contraction.  The  large  venous 
sinuses  are  placed  in  layers,  one  above  the  other,  in  the  thickness  of  the 
uterine  walls,  and  they  anastomose  freely.  ^When  the  superimposed 
layers  communicate  wdth  those  immediately  below  them,  the  junction  is 
by  a  falciform  or  semilunar  opening  in  the  floor  of  the  vessel  nearest  the 
external  surface  of  the  uterus.  Within  the  margins  of  this  aperture 
there  are  muscular  fibres,  the  contraction  of  which  probably  tends  to 
prevent  retrogression  of  blood  from  one  layer  of  vessels  into  the  other. 
The  venous  sinuses  themselves  are  of  a  flattened  form,  and  they  are  inti- 
mately attached  to  the  muscular  tissues.  It  is  obvious,  then,  that  these 
anatomical  arrangements  are  eminently  adapted  to  facilitate  the  closure 
of  the  vessels.  They  are,  however,  large,  and  are  destitute  of  valves  ; 
and  if  contraction  be  absent  or  if  it  be  partial  and  irregular,  it  is  equally 
easy  to  understand  why  blood  should  pour  forth  in  the  appalling  amount 
which  is  sometimes  observed 

Importance  of  Tonic  Uterine  Contraction. — If  uterine  action  be  firm, 
regular,  and  continuous,  the  vessels  must  be  sealed  up  and  hemorrhage 
effectually  prevented.  This  fact  has  been  doubted  by  many  authorities. 
Gooch  was  the  first  to  describe  Avhat  he  called  "  a  peculiar  form  of  hem- 
orrhage "  accompanying  a  contracted  womb ;  similar  observations  have 
been  made  by  other  writers,  such  as  Velpeau,  Rigby,  and  Gendrin. 
Simpson  says  on  this  point  that  strong  uterine  contractions  "  are  not 
probably  so  essential  a  part  in  the  mechanism  of  the  prevention  of  hem- 
orrhage from  the  open  orifices  of  the  uterine  veins  as  we  might,  a  priori, 
suppose."  ^  With  regard  to  Gooch's  cases  it  has  been  pointed  out  that 
his  own  description  proves  that,  how^ever  firmly  the  uterus  may  have 
contracted  immediately  after  the  expulsion  of  the  child,  it  must  have 
subsequently  relaxed,  for  he  passed  his  hand  into  it  to  remove  retained 
clots — a  manoeuvre  which  he  could  not  have  practised  had  tonic  con- 
traction been  present.  In  some  of  these  cases  the  hemorrhage  has  been 
found  to  come  from  a  laceration  of  the  cervix.  Of  course,  blood  may 
readily  escape  from  mechanical  injury  of  this  kind,  although  the  uterus 
itself  be  in  a  satisfactory  state  of  contraction  ;  and  the  possibility  of  this 
occurrence  should  always  be  borne  im-mind.  Instances  of  the  successful 
treatment  of  this  variety  of  post-partum  hemorrhage  by  sutures  applied 
to  the  lacerated  cervix  have  been  related  by  Fallen  and  others. 

Although,  then,  we  may  admit  that  post-partum  hemorrhage  is 
incompatible  with  persistent  contraction  of  the  uterus,  it  by  no  means 
follows  that  the  converse  is  true.  On  the  contrary,  it  is  not  uncommon 
to  meet  with  cases  in  which  the  uterus  is  large  and  apparently  quite 

1  Selected  Obst.  Worki<,  p.  234. 


HEMORRHAGE  AFTER  DELIVERY. 


417 


flaccid,  and  in  which  there  is  no  loss  of  blood.  Alternate  relaxation  and 
contraction  of  the  uterus  after  delivery  are  also  of  constant  occurrence, 
and  yet  hemorrhage  during  the  relaxation  does  not  take  place.  The 
explanation,  no  doubt,  is,  that  immediately  after  the  birth  of  the  child 
there  was  sufficient  contraction  to  prevent  hemorrhage,  and  that  during 
its  continuance  coagula  formed  in  the  mouths  of  the  uterine  sinuses,  by 
which  they  were  sufficiently  occluded  to  prevent  any  loss  when  subse- 
quent relaxation  occurred. 

In  all  probability,  both  uterine  contraction  and  thrombosis  are  in 
operation  in  ordinary  cases ;  and  we  shall  presently  see  that  all  the 
means  employed  in  the  treatment  of  post-partum  hemorrhage  act  by 
producing  one  or  other  of  them. 

Secondary  Causes  of  Hemorrhage. — Uterine  inertia  after  labor,  then, 
may  be  regarded  as  the  one  great  primary  cause  of  post-partum  hemor- 
rhage ;  but  there  are  various  secondary  causes  which  tend  to  produce  it, 
one  of  the  most  frequent  of  which  is  exhaustion  following  a  protracted 
labor.  The  uterus  gets  worn  out  by  its  efforts,  and  when  the  foetus  is 
expelled  it  remains  in  a  relaxed  state,  and  hemorrhage  results.  Over- 
distension of  the  uterus  acts  in  the  same  way.  Hence,  hemorrhage  is 
very  frequently  met  with  when  there  has  been  an  excessive  amount  of 
liquor  amnii  or  in  multiple  pregnancies.  One  of  the  worst  cases  I  ever 
met  with  was  after  the  birth  of  triplets,  the  uterus  having  been  of  an 
enormous  size.  Rapid  emptying  of  the  uterus,  during  which  there  has 
not  been  sufficient  time  for  complete  separation  of  the  placenta,  often  , 
tends  to  the  same  result.  This  is  the  reason  why  hemorrhage  so  fre- 
quently follows  forceps  delivery,  especially  if  the  operation  have  been 
unduly  hurried,  and  it  is  one  of  the  chief  dangers  in  what  are  termed 
"  precipitate  labors."  The  general  condition  of  the  patient  may  also 
strongly  predispose  to  it.  Thus,  it  is  more  often  met  with  in  women 
who  have  borne  families,  especially  if  they  be  weakly  in  constitution, 
comparatively  seldom  in  primiparse ;  and  for  the  same  reason  that  after- 
pains  are  most  common  in  the  former — namely,  that  the  uterus,  weak- 
ened by  frequent  childbearing,  contracts  inefficiently.  The  experience 
of  practitioners  in  the  tropics  shows  that  European  women,  debilitated 
by  the  relaxing  effects  of  warm  climates,  are  peculiarly  prone  to  it,  and 
it  forms  one  of  the  chief  dangers  of  childbirth  amongst  the  English 
ladies  in  India. 

Irregular  Uterine  Contraction. — Another  important  cause  of  post-  I 
partum  hemorrhage  is  partial  and  irregular  contraction  of  the  uterus. 
Part  of  the  muscular  tissue  is  firmly  contracted,  while  another  part  is 
relaxed,  and  the  latter  very  often  the  placental  site.  This  has  been  ' 
especially  dwelt  on  by  Simpson.  He  says :  "  The  morbid  condition 
wliicli  is  most  frequently  and  earliest  seen  in  connection  with  post- 
partum hemorrhage  is  a  state  of  irregularity  and  want  of  equability  in 
the  contractile  action  of  different  parts  of  the  uterus — and,  it  may  be,  in 
different  planes  of  the  muscular  fibres — as  marked  by  one  or  more 
points  in  the  organ  feeling  hard  and  contracted,  at  the  same  time  that 
otlif;r  ])ortions  of  the  ])arietes  are  soft  and  relaxed." 

JI()iir-g/(/ns  (Joidractlov, — One  jx'cnliar  variety,  whicli  lias  been  much 
dwelt  on  by  writers  and  is  a  prominent  bngljear  to  obstetricians,  is  the 

27 


t^f 


0 


f^ 


418 


LABOR. 


so-called  "  hour-glass  contraction.''^  This  in  reality  seems  to  depend  on 
spasmodic  contraction  of  the  internal  os  uteri,  by  means  of  which  the 
placenta  becomes  encysted  in  the  upper  portion  of  the  uterus,  which  is 
relaxed.  On  introducing  the  hand  it  first  passes  through  the  lax  cer- 
vical canal  until  it  comes  to  the  closed  internal  os,  with  the  um]:)ilical 
cord  passing  through  it,  which  has  generally  been  supposed  to  be  a  cir- 
cular contraction  of  a  portion  of  the  body  of  the  uterus. 

Encystment  of  the  placenta,  however,  although  more  rare,  unques- 
tionably takes  place  in  a  portion  only  of  the  body  of  the  uterus  (Fig. 
145).     Then,  apparently,  the  placental  site  remains  more  or  less  para- 

FiG.  145. 


Irregular  Contraction  of  the  Uterus,  with  Encystment  of  the  Placenta. 

lyzed,  with  the  placenta  still  attached,  while  the  remainder  of  the  body 
of  the  uterus  contracts  firmly,  and  thus  encystment  is  produced. ['] 

Causes  of  Irregular  Contractions. — These  irregular  contractions  of 
the  uterus  are  by  no  means  so  common  as  our  older  authors  supposed. 

r^  The  central  constriction  of  the  right-hand  figure  is  intended  to  represent  the  inter- 
nal OS  uteri.  The  condition  of  the  left-hand  illustration,  with  a  contraction  around  one 
corner,  I  have  very  distinctly  defined  in  a  case  of  retained  ]ilacenta.  The  adherent 
placenta  was  entirely  enclosed,  and  the  contJ-acted  portion  barely  sufficed  to  admit  the 
hand.  When  the  adhesion  was  broken  itp,  the  inert  portion  of  the  uterine  Mall  at  once 
contracted  :  this  was  no  doubt  partly  the  result  of  the  removal  of  tlie  mechanical  obsta- 
cle, and  partly  due  to  the  stinmlating  effect  of  the  presence  and  work  of  the  hand. 
This  experience  is  in  correspondence  with  the  opinion  of  the  late  Prof.  C.  D.  Meigs, 
who  taught  that  an  irrec/ularly-contracted  uterus  iwf-s  the  effect  of  an  adherent  placenta  acting 
as  an  obstacle  to  contraction  over  the  seat  of  union,  while  the  rest  of  the  organ  was  free  to 
contract.  Whether  the  central  muscular  fibres  of  the  uterus  can  ever  contract  so  as  to 
constrict  the  organ  is  a  question  which  has  long  been  in  dispute.  Those  who  deny  its 
possibility  do  so  upon  anatomical  reasoning,  claiming  that  the  arrangement  of  the  cir- 
cular muscular  fibres  is  such  that  a  violent  linear  contraction  in  the  corpus  uteri  is  an 
anatomical  impossibility.  Those  who  have  had  under  care  cases  of  ''  tetanoid  constric- 
tion of  the  uterus"  are  much  exercised  as  to  the  exact  location  of  the  spasmodic  band 
of  fibres  which  has  been  found  both  circular  and  oblique  and  tightly  surrounding  the 
body  of  the  fcetus.  The  discovery  of  Bandl  of  Vienna  (see  p.  433, "chap,  xvi.)  might 
possibly  account  for  the  condition  found  in  one  of  the  cases  of  Dr.  T.  A.  Foster  of  Port- 
land. Maine  (Transactions  Maine  Med.  Associaliou,  1868-69.  p.  273),  where  the  child  was 
tightly  lield  by  tlie  neck,  but  for  the  fact  that  the  uterine  walls  M-ere  thicker  than  nor- 
mal. Dr.  Thomas  C.  Smith  of  Washington,  D.  C,  has,  I  think,  made  it  clear  that 
tetanoid  constriction  mav  occur  in  the  body  of  the  uterus.  (See  Am.  Journ.  of  Obstet- 
rics, April,  1882,  pp.  294^322.;— Eu.] 


HEMORRHAGE  AFTER  DELIVERY.  419 

When  they  do  occur,  I  believe  them  ahiiost  invariably  to  depend  on 
defective  management  of  the  third  stage  of  labor.  "  The  most  frequent 
cause,"  says  Rigby,^  "  is  from  over-anxiety  to  remove  the  placenta ;  the 
cord  is  frequently  pulled  at,  and  at  length  the  os  uteri  is  excited  to  con- 
tract." While  this  is  being  done  no  attempts  are  probably  being  made 
to  excite  the  fundus  to  proper  action,  and  therefore  the  hour-glass  con- 
traction is  established.  Duncan  says  of  this  condition,  "  Hour-glass 
contraction  cannot  exist  unless  the  parts  above  the  contraction  are  in  a 
state  of  inertia  ;  were  the  higher  parts  of  the  uterus  even  in  moderate 
iaction  the  hour-glass  contraction  would  soon  be  overcome."^  If  pla- 
cental expression  were  always  employed,  if  it  were  the  rule  to  effect  the  , 
expulsion  of  the  placenta  by  a  vis  a  tergo  instead  of  extracting  by  a  vis  '■ 
afi'onte,  I  feel  confident  that  these  irregular  and  spasmodic  contractions 
— of  the  influence  of  which  in  producing  hemorrhage  there  can  be  no  ques- 
tion— would  rarely,  if  ever,  be  met  with.  It  is  to  be  observed  that  even 
in  these  cases  it  is  not  because  the  uterus  is  in  a  state  of  partial  contrac- 
tion, but  because  it  is  in  a  state  of  partial  relaxation,  that  hemorrhage 
ensues. 

Placental  Adhesions. — x4,dliesions  of  the  placenta  to  the  uterine  pari-  ' 
etes  may  cause  hemorrhage,  especially  if  they  be  partial  and  the  j 
remainder  of  the  placenta  be  detached.  The  frequency  of  these  has  I 
been  over-estimated.  Many  cases  believed  to  be  examples  of  adherent 
placentse  are,  in  reality,  only  cases  of  placentae  retained  from  uterine 
inertia.  The  experience  of  all  who  see  much  midwifery  will  probably 
corroborate  the  observation  of  Braun,  that  "  abnormal  adhesion  and 
hour-glass  contraction  are  more  frequently  encountered  in  the  experience 
of  the  young  practitioner^  and  they  diminish  in  frequency  in  direct  ratio 
to  increasing  years."  ^  The  cause  of  adhesion  is  often  obscure,  but  it 
most  probably  results  from  a  morbid  state  of  the  decidua,  which  is  pro- 
duced by  antecedent  disease  of  the  uterine  mucous  membrane  ;  then  the 
adhesion  is  apt  to  recur  in  subsequent  pregnancies.  The  decidua  is 
altered  and  thickened,  and  patches  of  calcareous  and  fibrous  degenera- 
tion may  be  often  found  on  the  attached  surface  of  the  placenta.  Most 
frequently  the  placenta  is  only  partially  adherent ;  patches  of  it  remain 
firmly  attached  to  the  uterus,  while  the  rest  is  separated ;  hence  the 
uterine  walls  remain  relaxed  and  hemorrhage  frequently  follows.  The 
diagnosis  and  management  of  these  very  troublesome  cases  will  be  found 
described  under  the  head  of  Treatment  (p.  423). 

Constitutional  Predisposition  to  Flooding. — Finally,  I  think  it  must 
be  admitted  that  there  are  some  women  who  really  merit  the  appellation 
of  "flooders"  which  has  been  applied  to  them,  and  who,  do  what  we 
may,  have  the  most  extraordinary  tendency  to  hemorrhage  after  delivery. 
I  do  not  think  that  these  cases,  however,  arc  by  any  means  so  common 
as  some  have  supposed.  I  have  attended  several  patients  who  have 
nearly  lost  their  lives  from  post-partum  hemorrhage  in  former  labors, 
some  who  have  suffered  from  it  in  every  preceding  confinement,  and  I 
have  only  met  with  two  cases  in  Avhich  the  assiduous  use  of  preventive 
treatment  failed  to  avert  it.     In  these  (one  of  which  I  have  elsewhere 

'  Kiijliy's  Midwifery,  p.  225.  ^  Researches  in  Obstetrics,  p.  389. 

^  Braun's  Lectures,  1869. 


420  LABOR. 

published  in  detail^),  in  spite  of  all  my  eiforts,  I  could  not  succeed  in 
keeping  up  uterine  contraction,  and  the  patients  would  certainly  have 
lost  their  lives  were  it  not  for  the  means  which  modern  improvements 
have  fortunately  placed  at  our  disposal  for  producing  thrombosis  in  the 
mouths  of  the  bleeding  vessels.  The  nature  of  these  rare  cases  requires 
further  investigation  ;  possibly  they  may,  to  some  extent,  be  the  subjects 
of  the  so-called  hemorrhagic  diathesis. 

^igns  and  Symptoms. — The  loss  of  blood  may  commence  immediately 
after  the  birth  of  the  child,  before  the  expulsion  of  the  placenta,  or  not 
until  some  time  afterward,  when  the  contracted  uterus  has  again  relaxed. 
It  may  commence  gradually  or  suddenly  :  in  the  latter  case  it  may  begin 
with  a  gush,  and  in  the  worst  form  the  bedclothes,  the  bed,  and  even  the 
floor,  are  deluged  with  the  blood  which,  it  is  no  exaggeration  to  say,  is 
pouring  from  the  patient.  If,  now,  the  hand  be  placed  on  the  abdomen, 
we  shall  miss  the  hard  round  ball  of  the  contracted  uterus,  which  will  be 
found  soft  and  flabby,  or  we  may  even  be  unable  to  make  out  its  contour 
at  all.  If  the  hemorrhao-e  be  slight  or  if  we  succeed  in  controlling  it  at 
once,  no  serious  consequences  follow ;  but  if  it  be  excessive  or  if  we  fail 
to  check  it,  the  gravest  results  ensue. 

Exhaustion  in  Extreme  Cbses. — There  are  few  sights  more  appalling  to 
witness  than  one  of  the  worst  cases  of  post-partum  hemorrhage.  The 
pulse  becomes  rapidly  affected,  and  may  be  reduced  to  a  mere  thread  or 
it  may  become  entirely  imperceptible.  Syncope  often  comes  on — not  in 
itself  always  an  unfavorable  occurrence,  as  it  tends  to  promote  throm- 
bosis in  the  venous  sinuses.  Or,  short  of  actual  syncope,  there  may  be 
a  feeling  of  intense  debility  and  faintness.  Extreme  restlessness  soon 
supervenes,  the  patient  throws  herself  about  the  bed,  tossing  her  arms 
M'ildly  above  her  head  ;  respiration  becomes  gasping  and  sighing,  the 
"  besoin  de  respirer"  is  acutely  felt,  and  the  patient  cries  out  for  more 
air ;  the  skin  becomes  deadly  cold  and  covered  with  profuse  perspiration ; 
if  the  hemorrhage  continue  unchecked,  we  next  may  have  complete  loss 
of  vision,  jactitation,  convulsions,  and  death. 

Formidable  as  such  symptoms  are,  it  is  satisfactory  to  know  that 
recovery  often  takes  place,  even  when  the  powers  of  life  seem  reduced  to 
the  lowest  ebb.  If  ^A'e  can  check  the  hemorrhage  while  there  is  still 
some  power  of  reaction  left,  however  slight,  we  may  not  unreasonably 
hope  for  eventual  recovery.  The  constitution,  however,  may  have 
received  a  severe  shock,  and  it  may  be  months,  or  even  years,  before  the 
patient  recovers  from  the  effects  of  only  a  few  minutes'  hemorrhage.  A 
death-like  pallor  frequently  follows  these  excessive  losses,  and  the 
patient  often  remains  blanched  and  exsanguine  for  a  long  time. 

Preventive  Treatment. — The  preventive  treatment  of  post-partum  hem- 
orrhage should  be  carefully  practised  in  every  case  of  labor,  however 
normal.  If  the  practitioner  make  a  habit  of  never  removing  his  hand 
from  the  uterus  after  the  birth  of  the  child  until  the  placenta  is  expelled, 
and  of  keeping  up  continuous  uterine  contraction  for  at  least  half  an 
hour  after  delivery  is  completed — not  necessarily  by  friction  on  the 
fundus,  but  by  simply  grasping  the  contracted  womb  with  the  palm  of 
the  hand  and  preventing  its  undue  relaxation — cases  of  post-partum 

^  Obst.  Journ.,  vol.  i. 


HEMORRHAGE  AFTER  DELIVERY.  421 

flooding  will  seldom  be  met  with.    As  a  rule,  we  should,  I  think,  not 
apply  the  binder  until  at  least  that  time  has  elapsed.     The  binder  is  an  • 
effective  means  of  keeping  up,  but  not  of  producing,  contraction,  and  it 
should  never  be  trusted  to  for  the  latter  purpose.     If  it  be  put  on  too  ! 
soon,  the  uterus  may  relax  under  it,  and  become  filled  with  clots  without 
the  practitioner  knowing  anything  about  it ;  whereas  this  cannot  possibly 
take  place  as  long  as  the  uterine  globe  is  held  in  the  hollow  of  the  hand. 
I  have  seen  more  than  one  serious  case  of  concealed  hemorrhage  result 
from  the  too  common  habit  of  putting  on  the  binder  immediately  after 
the  removal  of  the  placenta.     I  believe  also,  as  I  have  formerly  said,  , 
that  it  is  thoroughly  good  practice  to  administer  a  full  dose  of  the  liquid   \ 
extract  of  ergot  in  all  cases  after  the  placenta  has  been  expelled,  to  ensure  ' 
persistent  contraction  and  to  lessen  the  chance  of  blood-clots   being  j 
retained  in  utero. 

These  are  the  precautions  which  should  be  used  in  all  cases  alike  ;  but 
when  we  have  reason  to  fear  the  occurrence  of  hemorrhage  from  the  his- 
tory of  previous  labors  or  other  cause,  special  care  should  be  taken.  The 
ergot  should  be  given,  and  preferably  in  the  form  of  the  subcutaneous 
injection  of  ergotin,  before  the  birth  of  the  child,  when  the  presentation 
is  so  far  advanced  that  Ave  estimate  that  labor  will  be  concluded  in  from 
ten  to  twenty  minutes,  as  we  can  hardly  expect  the  drug  to  produce  any 
effect  in  less  time.  Particular  attention,  moreover,  should  then  be  paid 
to  the  state  of  the  uterus.  Every  means  should  be  taken  to  ensure 
regular  and  strong  contraction,  and  it  is  advisable  to  rupture  the  mem- 
branes early,  as  soon  as  the  os  is  dilated  or  dilatable,  to  ensure  stronger  ^ 
uterine  action.  If  any  tendency  to  relaxation  occur  after  delivery,  a  ^ 
pi^cejof_ice  should  be  passed  into  the  vagina  or  into  the  uterus.  Should 
coagula  collect  in  the  uterus,  they  may  be  readily  expelled  by  firm 
pressure  on  the  fundus,  and  the  finger  should  be  passed  occasionally  up 
to  the  cervix,  and  any  which  are  felt  there  should  be  gently  picked  away. 

We  should  be  specially  on  our  guard  in  all  cases  in  which  the  pulse 
does  not  fall  after  delivery.  If  it  beat  at  1 00  or  more  some  ten  minutes 
or  a  quarter  of  an  hour  aft"er  the  birth  of  the  child,  hemorrhage  not 
unfrequently  follows  •  and  hence  it  is  a  good  practical  rule,  whicli  may 
save  much  trouble,  that  a  patient  should  never  be  left  unless  the  pulse 
has  fallen  to  its  natural  standard. 

Curative  Treatment. — As  there  are  only  two  means  which  nature 
adopts  in  the  prevention  of  post-partum  hemorrhage,  so  the  remedial 
measures  also  may  be  divided  into  two  classes:  1,  those  which  act  by 
the  ])roduction  of  uterine  contraction ;  2,  those  which  act  by  producing 
thrombosis  in  the  vessels.  Of  these,  the  first  are  the  most  commonly  i 
used  ;  and  it  is  only  in  the  worst  cases,  in  which  they  have  been 
assiduously  tried  and  have  failed,  that  we  resort  to  those  coming  under 
the  second  heading. 

Uterine  P^-essure. — The  patient  should  be  placed  on  her  back,  in 
whicli  position  we  can  more  readily  command  the  uterus  as  well  as 
attend  to  her  gen(!ral  state.  If  the  uterus  l)e  found  relaxed  and  full  of 
clots,  l)y  firmly  grasping  it  in  the  hand  contraction  may  be  evoked,  its 
contents  ex])elled,  and  further  hemorrhage  at  once  arrested.  Should 
this,  fi)rtunately,  be  the  case,  we  must  keep  up  contraction  by  gently 


422  LABOR. 

kneading  the  uterus  until  we  are  satisfied  that  undue  relaxation  will  not 
recur. 

The  powerful  influence  of  friction  in  promoting  contraction  cannot 
be  doubted,  and  nothing  will  replace  it;  no  doubt  it  is  fatiguing,  but 
as  long  as  it  is  effectual  it  must  be  kept  up.  No  roughness  slioukl  be 
used,  as  we  might  produce  subsequent  injuiy,  but  it  is  quite  possible  to 
use  considerable  pressure  without  any  violence. 

Another  method  of  applying  uterine  pressure  has  been  strongly  advo- 
cated by  Dr.  Hamilton  of  Falkirk,  and  it  may  be  serviceable  where 
there  is  a  constant  draining  from  the  uterus  and  a  capacious  pelvis.  It 
consists  in  passing  the  fingers  of  the  right  hand  high  up  into  the 
posterior  cul-de-sac  of  the  vagina  so  as  to  reach  the  posterior  surface  of 
the  uterus,  while  counter-pressure  is  exercised  by  the  left  hand  through 
the  abdomen.  The  anterior  and  posterior  Avails  of  the  uterus  are  thus 
closely  pressed  together. 

Administration  of  Ei^got. — During  the  time  that  pressure  is  being 
applied  attention  can  be  paid  to  general  treatment ;  and  in  giving  his 
directions  to  the  bystanders  the  practitioner  should  be  calm  and  collected, 
avoiding  all  hurry  and  excitement.  A  full  dose  of  ergot  should  be 
administered,  and  if  one  have  already  been  given  it  should  be  repeated. 
We  cannot,  however,  look  upon  ergot  as  anything  but  a  useful  accessory, 
and  it  is  one  which  requires  considerable  time  to  operate.  The  hypo- 
dermic use  of  ergotin  offers  the  double  advantage,  in  severe  cases,  of 
acting  with  greater  power  and  much  more  rapidly  than  the  usual  method 
of  administration.  It  should,  therefore,  always  be  used  in  preference. 
An  aqueous  solution  of  ergotinin,  -jouth  of  a  grain  in  10  minims,  has  been 
highly  recommended  by  Cliahbazain  of  Paris  as  acting  more  energetically, 
but  of  this  I  have  no  experience.^ 

Stimulants. — The  sudden  flow  will  probably  have  produced  exhaus- 
tion and  a  tendency  to  syncope,  and  the  administration  of  stimulants 
]  M'ill  be  necessary.  The  amount  must  be  regulated  by  the  state  of  the 
I  pulse  and  the  degree  of  exhaustion.  There  is  no  more  absurd  mistake, 
I  however,  than  implicitly  relying  on  the  brandy-bottle  to  check  post- 
■  partum  hemorrhage.  In  the  worst  cases  absorption  is  in  abeyance,  and 
brandy  may  be  poured  down  in  abundance,  the  practitioner  believing 
that  he  is  rousing  his  patient,  while  he  is,  in  fact,  only  filling  the  stomach 
with  a  quantity  of  fluid  which  is  eventually  thrown  up  unaltered.  I 
have  more  than  once  seen  symptoms  produced  by  the  over-free  use  of 
brandy  in  slight  floodings  which  were  certainly  not  those  of  hemorrhage. 
I  remember  on  one  occasion  being  summoned  by  a  practitioner,  with  a 
view  to  transfusion,  to  a  patient  who  was  said  to  be  insensible  and  col- 
lapsed from  hemorrhage.  I  found  her,  indeed,  unconscious,  but  with 
a  flushed  face,  a  bounding  pulse,  a  firmly-contracted  uterus,  and  deep 
stertorous  breathing.  On  inquiry  I  ascertained  that  she  had  taken  an 
enormous  quantity  of  brandy,  which  had  brought  on  the  coma  of  pro- 
found intoxication,  while  the  hemorrhage  had  obviously  never  been 
excessive. 

Hypodermic  Injection  of  Ether. — The  hypodermic  injection  of  sul- 
I  phuric  ether  is  a  remedy  of  great  value  as  a  powerful  stimulant  in  cases 

1  Obst.  Trans.,  1882. 


HEMORRHAGE  AFTER  DELIVERY.  423 

in  which  exhaustion  is  very  great.  It  has  the  advantage  of  acting  rap- 
idly and  of  being  capable  of  administration  when  the  patient  is  unable 
to  swallow.  A  fluidrachm  may  be  injected  into  the  nates  or  thigh,  and 
the  injection  may  be  repeated  as  the  state  of  the  patient  may  require. 

Fresh  Air,  etc. — The  window  should  be  thrown  widely  open,  to  allow  I 
a  current  of  fresh  cold  air  to  circulate  freely  through  the  room.     The 
pillows  should  be  removed,  the  head  kept  low,  and  the  patient  should ' 
l3e  assidUiOusly  fanned. 

Emptying  of  Uterus. — If  bleeding  continue,  or  if  it  conuiience  before 
the  placenta  is  expelled,  the  hand  should  be  carefully  and  gently  passed 
into  the  uterus  and  its  cavity  cleared  of  its  contents.  The  mere  presence 
of  the  hand  within  the  uterus  is  a  powerful  inciter  of  uterine  action. 
When  the  placenta  is  retained  it  is  the  more  essential,  as  the  hemor- 
rhage cannot  possibly  be  checked  as  long  as  the  uterus  is  distended  by 
it.  During  the  operation  the  uterus  should  be  supported  by  the  left 
hand  externally,  and  by  using  the  two  hands  in  concert  the  chances  of 
injuring  the  textures  are  greatly  lessened. 

Treatment  of  Hour-glass  Contraction. — If  the  so-called  "■  hour-glass 
contraction"  be  present  or  if  the  placenta  be  morbidly  adherent,  the 
operation  w^ill  be  more  difficult  and  will  require  much  judgment  and 
care.  The  spasmodic  contraction  of  the  inner  os  in  the  former  case  may 
generally  be  overcome  by  gentle  and  continuous  pressure  of  the  fingers 
passed  within  the  contraction,  while  the  uterus  is  supported  from  with- 
out. By  this  means,  too,  further  hemorrhage  can  in  most  cases  be  con- 
trolled until  the  spasm  is  sufficiently  relaxed  to  admit  of  the  passage  of 
the  hand. 

Signs  of  Adherent  Placenta. — There  are  no  very  reliable  signs  to  indi- 
cate morbid  adhesion  of  the  placenta  previous  to  the  introduction  of  the 
hand.  The  following  are  the  symptoms  as  laid  down  by  Barnes,  any 
of  which  might,  however,  accompany  non-detachment  of  the  placenta 
unaccompanied  by  adhesion :  "  You  may  suspect  morbid  adhesion  if 
there  have  been  unusual  difficulty  in  removing  the  placenta  in  previous 
labors ;  if  during  the  third  stage  the  uterus  contracts  at  intervals  firmly, 
each  contraction  being  accompanied  by  blood,  and  yet  on  following  up 
the  cord  you  feel  the  placenta  in  utero  ;  if  on  pulling  on  the  cord,  two 
fingers  being  pressed  into  the  placenta  at  the  root,  you  feel  the  placenta 
and  uterus  clescend  in  one  mass,  a  sense  of  dragging  pain  being  elicited ; 
if  during  a  pain  the  uterine  tumor  does  not  present  a  globular  form,  but 
be  more  prominent  than  usual  at  the  place  of  placental  attachment."  ^ 

Treatment  of  Adherent  Placenta. — The  artificial  removal  of  an  adhe- 
rent placenta  is  always  a  delicate  and  anxious  operation,  which,  however 
carefully  performed,  must  of  necessity  expose  the  patient  to  the  risk  of 
injury  to  the  uterine  structures,  and  of  leaving  behind  portions  of  pla- 
centid  tissue,  whicli  may  give  rise  to  secondary  hemorrhage  or  septi- 
caemia. The  cord  will  guide  the  hand  to  the  site  of  attachment,  and  the 
fingers  must  be  very  gently  insinuated  between  the  lower  edge  of  the 
phicenta  and  the  uterine  wall ;  or,  if  a  portion  be  already  detached,  we 
may  commen(.'e  to  peel  off  the  remainder  at  that  si)ot.  Supporting  the 
uterus  externally,  we  carefully  pick  off  as  much  as  ptjssible,  proceeding 
'  Obstetric  Operations,  p.  440. 


424  LABOR. 

with  the  greatest  caution,  as  it  is  by  no  means  easy  to  distinguish  be- 
tween the  placenta  and  the  uterus.  At  the  best,  it  is  far  from  easy  to 
remove  all,  and  it  is  wiser  to  separate  only  what  we  readily  can  than  to 
make  too  protracted  efforts  at  complete  detachment.  When  it  is  found 
to  be  impossible  to  detach  and  remove  the  whole  or  a  great  part  of  the 
placenta.  Me  cannot  but  look  upon  the  further  progress  of  the  case  Avith 
considerable  anxiety.  The  retained  portions  may  be  ere  long  spontane- 
ously detached  and  expelled,  or  they  may  decompose  and  give  rise  to  a 
feticl  dischai'ge  and  septic  infection.  Such  cases  must  be  treated  by  anti- 
septic intra-uterine  injections,  so  as  to  lessen  the  risk  of  absorption  as 
much  as  possible ;  but  until  the  retained  masses  have  been  expelled  and 
the  discharge  has  ceased  the  patient  must  be  considered  to  be  in  consid- 
erable danger.  In  a  few  rare  cases  there  is  reason  to  believe  that  con- 
siderable masses  of  retained  placental  tissue  have  been  entirely  absorbed. 
It  is  difficult  to  understand  so  strange  a  phenomenon,  but  several  well- 
authenticated  cases  are  recorded  in  which  there  seems  no  reason  to  doubt 
that  the  retained  placenta  was  removed  in  this  way.^ 

Excitement  of  Reflex  Action  by  Cold,  etc. — Various  means  are  used  for 
exciting  uterine  contraction  by  reflex  stimulation.  Amongst  the  most 
important  of  these  is  cold.  In  patients  who  are  not  too  exhausted  to 
respond  to  the  stimulus  applied  it  is  of  extreme  value.  But  to  be  of 
use  it  should  be  used  intermittently  and  not  continuously.  Pouring  a 
stream  of  cold  water  from  a  height  on  the  abdomen  is  a  not  uncommon, 
but  bad,  practice,  as  it  deluges  the  patient  and  the  bedding  in  Mater, 
M'hich  may  afterward  act  injuriously.  Flapping  the  lower  part  of  the 
^abdomen  with  a  wet  to'svel  is  less  objectionable.  Ice  can  generally  be 
obtained,  and  a  piece  .should  be  introduced  into  the  uterus.  This  is  a 
very  powerful  hsemostatic,  and  often  excites  strong  action  Mdien  other 
means  fail.  I  constantly  employ  it,  and  have  never  seen  any  bad 
results  follow.  A  large  piece  of  ice  may  also  be  held  over  the  fundus, 
and  removed  and  reapplied  from  time  to  time.  Iced  water  may  be 
injected  into  the  rectum.  A  very  poAverful  remedy  is  washing  out  the 
uterine  cavity  with  a  stream  of  cold  water  by  means  of  a  vaginal  pipe 
of  a  Higginson's  syringe  carried  up  to  the  fundus.  Another  means  of 
applying  cold,  said  to  be  very  effectual,  is  the  application  of  the  ether 
spray,  such  as  is  used  for  producing  local  anaesthesia,  over  the  lower 
part  of  the  abdomen.^  All  these  remedies,  hoM^ever,  depend  for  their  good 
results  on  the  fact  of  the  patient  being  in  a  condition  to  respond  to  stim- 
ulus, and  their  prolongecl  use,  if  they  fail  to  excite  contraction  rapidly, 
will  certainly  prove  injurious.  Rigby  used  to  look  upon  the  application 
of  the  child  to  the  breast  as  one  of  the  most  certain  inciters  of  uterine 
action.  It  may  be  of  service,  after  the  hemorrhage  has  been  checked, 
in  keeping  up  tonic  contraction,  and  should  therefore  not  be  omitted ; 
but  we  certainly  cannot  M^aste  time  in  inducing  the  child  to  suck  in  the 
face  of  the  actual  emergency. 

Intra-uterine  Injections  of  Hot  Water. — Of  late,  intra-uterine  injec- 
tions of  hot  water,  at  a  temperature  of  from  100°  to  120°,  have  been 

'  See  an  interesting  paper  by  Dr.  Thrush  on  "  Retention  of  the  Placenta  in  Labor  at 
Term,"  Amei:  Journ.  of  Obstet.,  July,  1877. 
^  Griffiths,  Practitioner,  March,  1877. 


HEMORRHAGE  AFTER  DELIVERY.  425 

highly  recommended  as  a  powerful  means  of  arresting  post-partum  hem-  ' 
orrhage,  often  proving  effectual  M^ien  all  other  treatment  has  failed. 
The  number  of  published  cases  in  which  it  has  proved  of  great  value  is 
now  considerable.  The  present  Master  of  the  Rotunda,  Dr.  Lombe 
Atthill,  has  recorded  16  cases  ^  in  which  it  checked  hemorrhage  at  once, 
in  many  of  which  ergot,  ice,  and  other  means  had  failed.  He  speaks 
of  it  as  especially  useful  in  those  troublesome  cases  in  which  the  uterus 
alternately  relaxes  and  hardens,  and  resists  all  our  efforts  to  produce 
permanent  contraction.  My  own  experience  of  this  treatment  is  very 
favorable.  I  have  now  used  it  in  several  cases,  in  some  of  which  the 
tendency  to  hemorrhage  was  very  great,  and  in  every  instance  it  has  at 
once  produced  strong  uterine  action  and  instantly  checked  the  flow.  It 
is,  moreover,  much  more  agreeable  to  the  patient  than  cold  applications. 
I  think  it  cannot  be  doubted  that  we  have  in  these  hot  irrigations  a 
valuable  addition  to  our  methods  of  treating  uterine  hemorrhage.         | 

State  of  the  Bladder. — The  late  Dr.  Earle  pointed  out^  that  a  dis-  j 
tended  bladder  often  prevents  contraction,  and  to  avoid  the  possibility  | 
of  this  the  catheter  should  be  passed. 

Plugging  of  the  Vagina. — Plugging  of  the  vagina  has  often  been  used. 
It  is  only  necessary  to  mention  it  for  the  purpose  of  insisting  on  its 
absolute  inapplicability  in  all  cases  of  post-partum  hemorrhage ;  the 
only  effect  it  could  have  would  be  to  prevent  the  escape  of  blood  exter- 
nally, which  might  then  collect  to  any  extent  in  the  cavity  of  the  uterus. 

Compression  of  the  Abdominal  Aorta. — Compression  of  the  abdomi- 
nal aorta  is  highly  thought  of  by  many  continental  authorities,  but  it  is 
little  known  or  practised  in  this  country.  It  has  been  objected  to  by 
some  on  the  theoretical  ground  that  the  hemorrhage  is  chiefly  venous, 
and  not  arterial,  and  that  it  would  only  favor  the  reflux  of  venous  blood 
into  the  vena  cava.  Cazeaux  points  out  that,  on  account  of  the  close 
anatomical  relations  between  the  aorta  and  the  vena  cava,  it  is  hardly 
possible  to  compress  one  vessel  within  the  other.  The  backward  flow 
of  blood,  therefore,  through  the  vena  cava  may  also  be  thus  arrested. 
There  is  strong  evidence  in  favor  of  the  occasional  utility  of  compres- 
sion. Its  chief  recommendation  is,  that  it  can  be  practised  immediately, 
and  by  an  assistant,  who  can  be  shown  how  to  apply  the  pressure.  It 
is  most  likely  to  prove  useful  in  sudden  and  severe  hemorrhage,  and  if 
it  only  control  the  loss  for  a  few  moments  it  gives  us  time  to  apply  other 
methods  of  treatment.  As  a  temporary  expedient,  therefore,  it  should 
be  borne  in  mind  and  adopted  when  necessary.  It  has  the  great  advan- 
tage of  supplementing,  without  superseding,  other  and  more  radical  plans 
of  treatment.  The  pressure  is  very  easily  applied  on  account  of  the  lax 
state  of  the  abdominal  walls.  The  artery  can  readily  be  felt  pulsating 
above  the  fundus  uteri,  and  can  be  compressed  against  the  vertebrae  by 
three  or  four  fingers  applied  lengthways.  BaudelDcque,  who  was  a 
strong  advocate  of  this  procedure,  states  that  he  has  on  several  occasions 
controlled  an  otherwise  intractable  hemorrhage  in  this  way,  and  that  he 
on  one  occasion  kept  up  compression  for  four  consecutive  hours.  Cazeaux 
believes  that  compression  of  the  aorta  may  have  a  further  advantageous 
effect  in  retaining  the  mass  of  the  blood  in  the  upper  part  of  the  body, 
'  jAinnd,  February  9,  1878.  ^  Earle's  Flooding  after  Delivery,  p.  163. 


426  LABOR. 

and  thus  lessening  the  tendency  to  syncope  and  collapse.  If  an  aortic 
tourniquet,  such  as  is  used  for  compressing  the  vessel  in  cases  of  aneur- 
ism, could  be  obtained,  it  might  be  used  with  advantage  in  such  cases. 

Faradic  Current. — If  a  battery  is  at  hand,  the  faradic  current  may  be 
used,  and  is,  it  is  said,  a  very  powerful  agent  in  inducing  uterine  con- 
traction, one  pole  being  introduced  into  the  uterus,  the  other  applied 
over  it  through  the  abdominal  parietes. 

Bandaging  of  the  Extremities. — When  the  hemorrhage  has  been  exces- 
sive and  there  is  profound  exhaustion,  firm  banclaging  of  tlie  extremi- 
ties, by  preference  with  Esmarch's  elastic  bandages  if  they  can  be 
obtained,  may  be  advantageously  adopted,  with  the  view  of  retaining 
the  blood  as  much  as  possible  in  the  trunk,  and  thus  lessening  the  tend- 
ency to  syncope.  As  a  temporary  expedient  in  the  worst  class  of  cases 
it  may  occasionally  prove  of  service. 

[Lives  of  patients  in  extremis  have  been  saved  by  the  expedient  of 
raising  the  body  of  the  woman  and  lowering  her  head,  so  as  to  turn  the 
current  of  blood  toward  the  brain.  This  may  have  to  be  repeated  sev- 
eral times  in  the  treatment  of  a  case  Avhere  attacks  of  syncope  indicate 
it.  A  bladder  containing  ice  may  be  held  under  the  hand  of  the  ope- 
rator over  the  abdomen  and  above  the  fundus  uteri,  and  compression 
made  upon  the  uterus  and  aorta  at  the  same  time.  In  one  case  I  was 
forced,  by  the  long-continued  inertia  of  the  uterus  and  the  tendency  to 
a  return  of  hemorrhage,  to  keep  up  this  form  of  compression  for  6-| 
hours.  The  hand  of  the  operator  should  be  protected  by  a  compress  of 
flannel,  or  he  may  have  an  attack  of  local  neuralgia,  or  possibly  rheu- 
matism, in  his  arm. — Ed.] 

Injection  of  Styptics. — Supposing  these  means  fail,  and  the  uterus 
1  obstinately  refuses  to  contract  in  spite  of  all  our  efforts — and,  do  what 
1  we  may,  cases  of  this  kind  will  occur — the  only  other  agent  at  our  com- 
I  mand  is  the  application  of  a  powerful  styptic  to  the  bleeding  surface  to 
1  produce  thrombosis  in  the  vessels.     "  The  latter,"  says  Dr.  Ferguson,' 
\  alluding  to  this  means  of  arresting  hemorrhage,  "  appears  to  be  the  sole 
means  of  safety  in  those  cases  of  intense  flooding  in  which  the  uterus 
flaps  about  the  hand  like  a  wet  towel.     Incapable  of  contraction  for 
hours,  yet  ceasing  to  ooze  out  a  drop  of  blood,  there  is  nothing  appar- 
ently between  life  and  death  but  a  few  soft  coagula  ])lugging  up  the 
i  sinuses."     These  form  but  a  frail  barrier  indeed,  but  the  experience  of 
i  all  who  have  used  the  injection  of  a  solution  of  perchloride  of  iron  in  such 
I  cases  proves  that  they  are  thoroughly  effectual,  and  its  introduction  into 
j  practice  is  one  of  the  greatest  improvements  in  modern  midwifery. 
Although  this  method  of  treating  these  obstinate  cases  is  not  new,  since 
it  was  practised  long  ago  in  Germany,  its  adoption  in  this  country  is 
unquestionably  due  to  the  energetic  recommendation  of  Dr.   Barnes. 
Although  the  dangers  of  the  practice  have  been  strongly  insisted  on, 
and  with  a  degree  of  acrimony  that  is  to  be  regretted,  I  know  of  only 
one  published  case  in  which  its  use  has  been  followed  by  any  evil  effects. 
Its  extraordinary  power,  however,  of  instantly  checking  the  most  for- 
midal)le  hemorrhage  has  been  demonstrated  by  the  unanimous  testimony 
of  all  who  have  tried  it.     As  it  is  not  proposed  by  any  one  that  this 

'  Preface  to  Gooch  On  Diseases  of  Womev,  p.  xlii. 


HEMORRHAGE  AFTER  DELIVERY.  427 

means  of  treatment  should  be  employed  until  all  ordinary  methods 
of  evoking  contraction  have  failed,  and  as,  in  cases  of  this  kind,  the 
lives  of  the  patients  are  of  necessity  imperilled,  we  should  be  fully  justi- 
fied in  adopting  it  even  if  its  possibly  injurious  effects  had  been  much 
more  certainly  proved.  It  is  surely  at  any  time  justifiable  to  avoid  a 
great  and  pressing  peril  by  running  a  possible  chance  of  a  less  one. 
Whenever,  therefore,  we  have  tried  the  plans  above  indicated  in  vain,  no 
time  should  be  lost  in  resorting  to  this  expedient.  No  practitioner  should 
attend  a  case  of  midwifery  without  having  the  necessary  styptic  with 
him.  The  best  and  most  easily  obtainable  form  of  using  the  remedy  is 
the  "liquor  ferri  perchloridi  fortior"  of  the  London  Pharmacopoeia, 
which  should  be  diluted  for  use  with  six  times  its  bulk  of  water.  This 
is  certainly  better  than  a  weaker  solution.  The  vaginal  pipe  of  a  Hig- 
ginson's  syringe,  through  wliich  the  solution  has  once  or  twice  been 
pumped  to  exclude  the  air,  is  guided  by  the  hand  to  the  fundus  uteri 
and  the  fluid  injected  gently  over  the  uterine  siu'face.  The  loose  and 
flabby  mucous  membrane  is  instantaneously  felt  to  pucker  up,  all  the 
blood  with  which  the  fluid  comes  in  contact  is  coagulated,  and  the 
hemorrhage  is  immediately  arrested.  I  think  it  is  of  importance  to 
make  sure  that  the  uterus  and  vagina  are  emptied  of  clots  before  injec- 
tion. In  the  only  cases  in  which  I  have  seen  any  bad  symptoms  follow 
this  precaution  had  been  neglected.  The  iron  hardened  all  the  coagula, 
which  remained  in  utero,  and  septicsemia  supervened ;  which,  however, 
disappeared  after  the  clots  had  been  broken  up  and  washed  away  by 
intra-uterine  antiseptic  injections.  After  we  have  resorted  to  this  treat- 
ment all  further  pressure  on  the  uterus  should  be  stopped.  We  must 
remember  that  we  have  now  abandoned  contraction  as  a  hsemostatic 
and  are  trusting  to  thrombosis,  and  that  pressiu'e  might  detach  and  less- 
en the  coagula  which  are  preventing  the  escape  of  blood. 

Other  local  astringents  may  be  eventually  found  to  be  of  use.  Tinc- 
ture of  matico  possibly  might  be  serviceable,  although  I  am  not  aware 
that  it  has  been  tried.  Dupierris  has  advocated  tincture  of  iodine,  and 
has  recorded  24  cases  in  which  he  employed  it — in  all  without  accident 
and  with  a  successful  issue.  Penrose  strongly  recommends  common  vin- 
egar, which  has  the  advantage  of  being  always  readily  obtainable.  But 
iKjthing  seems  likely  to  act  so  immediately  or  so  effectually  as  the  per- 
chloride  of  iron. 

Hemorrhage  from  Laceration  of  Maternal  Strudm^es. — A  word  may 
here  be  said  as  to  the  occasional  dependence  of  hemorrhage  after  delivery 
on  laceration  of  the  cervix  or  other  injury  to  the  maternal  soft  parts. 
Duncan  has  narrated  a  case  in  which  the  bleeding  came  from  a  ruptured 
])erineum.  If  liemorrliage  continue  after  the  uterus  is  permanently  con- 
tra(;ted,  a  carcfid  examination  should  be  made  to  ascertain  if  any  such 
injury  exist.  Most  generally  the  source  of  bleeding  is  the  cervix,  and 
the  flow  can  ho,  readily  arrested  by  swabbing  the  injured  textures  with  a 
sponge  saturated  in  a  solution  of  the  jierchloride. 

Hcconda/ry  Trcatnirtil. — The  secondary  treatment  of  ])ost-])artum  hem- 
orrhage is  of  iiiiporlancc.  When  reaction  commences  a  train  of  distress- 
ing syinj)toms  often  show  themselves,  such  as  intense  and  throbbing 
headache,  great  intolerance  of  light  and  sound,  and  general  nervous  j)ros- 


428  LABOR. 

tration ;  and  when  these  liave  passed  away  we  have  to  deal  with  tlie 
more  chronic  effects  of  profuse  loss  of  blood.  Nothing  is  so  valuable 
in  relieving  these  symptoms  as  opium.  It  is  the  best  restorative  that 
can  be  employed,  but  it  must  be  administered  in  larger  doses  than  usual. 
Tliirty  to  forty  drops  of  Battley's  solution  should  be  given  by  the  mouth 
or  in  an  enema.  At  the  same  time  the  patient  should  be  kept  perfectly 
still  and  quiet  in  a  darkened  room  and  the  visits  of  anxious  friends 
strictly  forbidden.  Strong^  beef-essence  or  gravy  soup^  milk,  or  eggs  beat 
up  with  milk,  and  similar  easily-absorbed  articles  of  diet  should  be 
given  frequently  and  in  small  quantities  at  a  time.  Stimulants  \vill  be 
required  according  to  the  state  of  the  patient,  such  as  warm  brandy  and 
water,  port  wine,  etc.  Rest  in  bed  should  be  insisted  on,  and  continued 
much  beyond  the  usual  time.  Eventually,  the  remedies  which  act  by 
promoting  the  formation  of  blood,  such  as  the  various  preparations  of 
iron,  will  be  found  useful  and  may  be  required  for  a  length  of  time. 

Transfusion. — Under  the  head  of  Transfusion  I  have  separately  treated 
the  application  of  that  last  resource  in  those  desperate  cases  in  which  the 
loss  of  blood  has  been  so  excessive  as  to  leave  no  other  hope. 

Secondary  Post-jpartum  Her)%orrhage. — In  the  majority  of  cases,  if  a 
few  hours  have  elapsed  after  delivery  without  hemorrhage,  we  may  con- 
sider the  patient  safe  from  the  accident.  It  is  by  no  means  very  rare,  how- 
ever, to  meet  with  even  profuse  losses  of  blood  coming  on  in  the  course 
of  convalescence  at  a  time  varying  from  a  few  hours  or  days  up  to  several 
weeks  after  delivery.  These  cases  are  described  as  examples  of  "  second-^ 
ary  hemorrhage/'  and  they  have  not  received  at  all  an  adequate  amount 
of  attention  from  obstetric  writers,  inasmuch  as  they  often  give  rise  to 
very  serious,  and  even  fatal,  results,  and  are  always  somewhat  obscure  in 
their  etiology  and  difficult  to  treat.  We  owe  almost  all  our  knowledge 
of  this  condition  to  an  excellent  paper  by  Dr.  McClintock  of  Dublin, 
who  has  collected  characteristic  examples  from  the  writings  of  various 
authors  and  accurately  described  the  causes  which  are  most  apt  to  pro- 
duce it. 

Profuse  Lochial  Discharge. — We  must,  in  the  first  place,  distinguish 
between  true  secondary  hemorrhage  and  profuse  lochial  discharge  con- 
tinued for  a  longer  time  tlian  usual.  The  latter  is  not  a  very  uncom- 
mon occurrence,  and  is  generally  met  with  in  cases  in  which  involution 
of  the  uterus  has  been  checked,  as  by  too  early  exertion,  general  debil- 
ity, and  the  like.  The  amount  of  the  lochial  discharge  varies  in  dif- 
ferent women.  In  some  patients  it  habitually  continues  during  the 
whole  puerperal  month,  and  even  longer,  but  not  to  an  extent  Avhich 
justifies  us  in  including  it  under  the  head  of  hemorrhage.  In  such  cases 
prolonged  rest,  avoidance  of  the  erect  posture,  occasional  small  doses  of 
ergot,  and,  it  may  be,  after  the  lapse  of  some  weeks,  astringent  injec- 
tions of  oak-bark  or  alum,  will  be  all  that  is  necessary  in  the  way  of 
treatment. 

True  secondary  hemorrhage  is  often  sudden  in  its  appearance  and  seri- 
ous in  its  effects.  McClintock  mentions  6  fatal  cases,  and  Mr.  Bassett 
of  Birmingham^  has  recorded  13  examples  which  came  under  his  own 
observation,  2  of  which  ended  fatally. 

1  Brit.  Med.  Journ.,  1872. 


HEMOBBHAGE  AFTEB  DELIVEBY.  429 

Causes. — The  causes  may  be  either  constitutional  or  some  local  con- 
dition of  the  uterus  itself. 

Constitutional  Causes. — Among  the  former  are  such  as  produce  a  dis- 
turbance of  the  vascular  system  of  the  body  generally  or  of  the  uterine 
vessels  in  particular.  The  state  of  the  uterine  sinuses,  and  the  slight 
barrier  which  the  thrombi  formed  in  them  oifer  to  the  escape  of  blood, 
readily  explain  the  fact  of  any  sudden  vascular  congestion  producing 
hemorrhage.  Thus,  mental  emotions,  the  sudden  assumption  of  the 
erect  posture,  any  undue  exertion,  the  incautious  use  of  stimulants,  a 
loaded  condition  of  the  bowels,  or  sexual  intercourse  shortly  after  deliv- 
ery, may  act  in  this  way.  McClintock  records  the  case  of  a  lady  in 
whom  very  profuse  hemorrhage  occurred  on  the  twelfth  day  after  labor 
when  sitting  up  for  the  first  time.  Feeling  faint  after  sucking,  the 
nurse  gave  her  some  brandy,  whereupon  a  gush  of  blood  ensued,  "  delug- 
ing all  the  bedclothes  and  penetrating  through  the  mattress  so  as  to  form 
a  pool  on  the  floor."  Here  the  erect  position,  the  exquisite  pain  caused 
by  nursing,  and  the  stimulating  drink,  all  concurred  to  excite  the  hemor- 
rhage. In  another  instance  the  flooding  was  traced  to  excitement  pro- 
duced by  the  sudden  return  of  an  old  lover  on  the  eighth  day  after  labor. 
Moreau  especially  dwells  on  the  influence  of  local  congestion  produced 
by  a  loaded  condition  of  the  rectum.  Constitutional  affections  produ- 
cing general  debility  and  an  impoverished  state  of  the  blood  probably 
also  may  have  the  same  effect.  Blot  specially  mentions  albuminuria  as 
one  of  these,  and  Saboia  states  that  in  Brazil  secondary  hemorrhage  is 
a  common  symptom  of  miasmatic  poisoning,  and  can  only  be  cured  by 
change  of  air  and  the  free  use  of  quinine.^ 

Local  Causes. — Local  conditions  seem,  however,  to  be  the  more  fre- 
quent factors  in  the  production  of  secondary  hemorrhage.  These  may  be 
generally  classed  under  the  following  heads  : 

1.  Irregular  and  inefficient  contraction  of  the  uterus. 

2.  Clots  in  the  uterine  cavity. 

3.  Portions  of  retained  placenta  or  membranes. 

4.  Retroflexion  of  the  uterus. 

5.  Laceration  or  inflammatory  state  of  the  cervix. 

6.  Thrombosis  or  hseniatocele  of  the  cervix  or  vulva. 

7.  Inversion  of  the  uterus. 

8.  Fibroid  tumors  or  polypus  of  the  uterus. 

The  first  four  of  these  need  only  now  be  considered,  the  others  being 
described  elsewhere. 

Relaxation  of,  and  Clots  in,  the  Uterus. — Relaxation  of  the  uterus  and 
distension  of  its  cavity  by  coagula  may  give  rise  to  hemorrhage,  although 
not  so  readily  as  immediately  after  delivery,  for  coagula  of  considerable 
size  are  often  retained  in  utero  for  many  days  after  labor.  The  uterus 
will  be  found  larger  than  it  ought  to  be,  and  tender  on  pressure.  Usually 
the  coagida  are  exj)elled  with  severe  after-pains;  but  this  may  not  take 
])lace,  and  hemorrhage;  may  ensue  several  days  aftc^r  delivery.  Or  there 
may  be  only  a  relaxcid  state  of  the  uterus  without  ivtainod  coagula. 
I>assett  relat(^s  four  cases  traced  to  these  causes,  and  several  illusti'ations 
will  l)(;  found  in  McClintock's  ])a])er.     Portions  of  retained  placenta  or 

'  Saboia,  Traite  den  Aceouchementfi,  p.  819. 


430  LABOR. 

membranes  are  more  frequent  causes.  The  retention  may  be  clue  to  care- 
lessness on  the  part  of  the  practitioner,  especially  if  he  have  removed 
the  placenta  by  traction  and  failed  to  satisfy  himself  of  its  integrity.  It 
mav,  however,  often  be  due  to  circumstances  entirely  beyond  his  control, 
such  as  adherent  placenta,  which  it  is  impossible  to  remove  without  leav- 
ing portions  in  utero,  or  more  rarely  placenta  succenturia.  In  the  latter 
case  there  is  a  small  supplementary  portion  of  placental  tissue  developed 
entirely  separate  from  the  general  mass,  and  it  may  remain  in  utero  M'ith- 
out  the  practitioner  having  the  least  suspicion  of  its  existence.  Portions 
of  the  membranes  are  very  apt  to  be  left  in  utero.  It  is  to  prevent  this 
that  they  should  be  twisted  into  a  rope  and  extracted  very  gently  after 
expression  of  the  placenta.  Hemorrhage  from  these  causes  generally 
does  not  occur  until  at  least  a  week  after  delivery,  and  it  may  not  do  so 
until  a  much  longer  time  has  elapsed.  In  four  cases  recorded  by  Mr. 
Bassett  it  commenced  on  the  tenth,  twelfth,  fourteenth,  and  thirty-second 
dav.  It  may  come  on  suddenly  and  continue,  or  it  may  stop,  and  recur 
frequently  at  short  intervals.  In  my  experience  retention  of  portions 
of  the  placenta  is  very  common  after  abortion,  when  adhesions  are  more 
generally  met  Avith  than  at  term.  In  addition  to  the  hemorrhage  there 
is  often  a  fetid  discharge  due  to  decomposition  of  the  retained  portion, 
and  possibly  more  or  less  marked  septicsemic  symptoms,  which  may  aid 
in  the  diagnosis.  The  placenta  or  membranes  may  simply  be  lying  loose 
as  foreign  bodies  in  the  uterine  cavity,  or  they  may  be  organically  at- 
tached to  the  uterine  walls,  when  their  removal  will  not  be  so  easily 
effected. 

Retroflexion. — Barnes  has  especially  pointed  out  the  influence  of  retro- 
flexion of  the  uterus  in  producing  secondary  hemorrhage,^  which  seems 
to  act  by  impeding  the  circulation  at  the  point  of  flexion  and  thus  arrest- 
ing the  process  of  involution. 

In  every  case  in  which  secondary  hemorrhage  occurs  to  any  extent 
careful  investigation  into  the  possible  causes  of  the  attack,  and  an  accu- 
rate vaginal  examination,  are  imperatively  required.  If  it  be  due  to 
general  and  constitutional  causes  only,  we  must  insist  on  the  most  abso- 
lute rest  on  a  hard  bed  in  a  cool  room  and  on  the  absence  of  all  causes 
of  excitement.  The  liquid  extract  of  ergot  will  be  very  generally  use- 
ful in  3j  doses  repeated  every  six  hours.  McClintock  strongly  recom- 
mends tiie  tincture  of  Indian  hemp,  which  may  be  advantageously  com- 
bined with  the  ergot,  in  doses  of  10  or  15  minims,  suspended  in  muci- 
lage. Astringent  vaginal  pessaries  of  matico  or  perchloride  of  iron  may 
be  used.  Special  attention  should  be  paid  to  the  state  of  the  bowels, 
and  if  the  rectum  be  loaded  it  should  be  emptied  by  enemata.  In  more 
chronic  cases  a  mixture  of  ergot,  sulphate  of  iron,  and  small  doses  of  sul- 
phate of  magnesia  will  prove  very  serviceable.  This  is  more  likely  to  be 
eifectual  when  the  bleeding  is  of  an  atonic  and  passive  character.  McClin- 
tock speaks  strongly  in  favor  of  the  application  of  a  blister  over  the  sac- 
rum. When  the  hemorrhage  is  excessive  more  effectual  local  treatment 
will  be  required.  Cazeaux  advises  plugging  of  the  vagina.  Although 
this  cannot  be  considered  so  dangerous  as  immediately  after  delivery,^  in- 
asmuch as  the  uterus  is  not  so  likely  to  dilate  above  the  plug,  still  it  is 
^  Obstetric  Operations,  p.  492. 


RUPTURE  OF  THE   UTERUS.  431 

certainly  not  .entirely  without  risk  of  favoring  concealed  internal  hemor- 
rhage. If  it  be  used  at  all,  a  firm  abdominal  pad  should  be  applied,  so 
as  to  compress  the  uterus ;  and  the  abdomen  should  be  examined  from 
time  to  time  to  ensure  against  the  possibility  of  uterine  dilatation.  With 
these  precautions  the  plug  may  prove  of  real  value.  In  any  case  of 
really  alarming  hemorrhage  I  should  be  disposed  rather  to  trust  to  the 
application  of  styptics  to  the  uterine  cavity.  The  injection  of  fluid  in 
bulk,  as  after  delivery,  could  not  be  safely  practised,  on  account  of  the 
closure  of  the  os  and  the  contraction  of  the  uterus.  But  there  can  be  no 
objection  to  swabbing  out  the  uterine  cavity  with  a  small  piece  of  sponge 
attached  to  a  handle  and  saturated  in  a  solution  of  the  perchloride  of 
iron.     There  are  few  cases  which  will  resist  this  treatment. 

If  we  have  reason  to  suspect  retained  placenta  or  membranes,  or  if 
the  hemorrhage  continue  or  recur  after  treatment,  a  careful  exploration 
of  the  interior  of  the  womb  will  be  essential.  On  vaginal  examination 
we  may  possibly  feel  a  portion  of  the  placenta  protruding  through  the 
OS,  which  can  then  be  removed  without  difficulty.  If  the  os  be  closed, 
it  must  be  dilated  with  sponge  or  laminaria  tents  or  by  a  small-sized 
Barnes's  bag,  and  the  uterus  can  then  be  thoroughly  explored.  This 
ought  to  be  done  under  chloroform,  as  it  cannot  be  effectually  accom- 
plished without  introducing  the  whole  hand  into  the  vagina,  which 
necessarily  causes  much  pain.  If  the  placenta  or  membranes  be  loose 
in  the  uterine  cavity,  they  may  be  removed  at  once,  or  if  they  be  organic- 
ally attached,  they  may  be  carefully  picked  oflp.  The  uterus  should  at 
the  same  time,  and  as  long  as  the  os  remains  patulous,  be  thoroughly 
washed  out  with  Condy's  fluid  and  water  to  diminish  the  risk  of  sep- 
ticaemia. 

Retroflexion  can  readily  be  detected  by  vaginal  examination  and  the 
trei\tme]it  consists  in  careful  reposition  Avith  the  hand  and  the  application 
of  a  large-sized  Hodge's  pessary. 


CHAPTER  XVI. 

EUPTURE  OF  THE  UTEKUS,  ETC. 

Its  FataUfjj. — Rupture  of  the  uterus  is  one  of  the  most  dangerous 
accidents  of  lal)or,  and  until  of  late  years  it  has  been  considered  almost 
necessarily  fatal  and  beyond  the  reach  of  treatment.  Fortunately,  it  is 
not  of  very  frequent  occurrence,  although  the  published  statistics  vary 
so  much  that  it  is  by  no  means  easy  to  arrive  at  any  conclusion  on  this 
point.  The  explanation  is,  no  doubt,  that  many  of  the  taljles  confound 
partial  and  comj)aratively  unimportant  lacerations  of  the  cervix  and 
vagina  with  rupture  of  the  body  and  fundus.  It  is  only  in  large  lying- 
in  institutions,  where  the  results  of  cases  are  accurately  recorded,  that 
anything  like  reliable  statistics  can  be  gathered,  for  in  private  practice 


432  LABOR. 

the  occurrence  of  so  lamentable  an  accident  is  likely  to  remain  unpub- 
lished. To  show  the  diiference  between  the  figures  given  by  authorities, 
it  may  be  stated  that  while  Burns  calculates  the  proportion  to  be  1  in 
940  labors,  Ingleby  fixes  it  as  1  in  1300  or  1400,  Churchill  as  1  in 
1331,  and  Lehmann  as  1  in  2433.  Dr.  Jolly  of  Paris  has  published  an 
excellent  thesis  containing  much  valuable  information.'  He  finds  that 
out  of  782,741  labors,  230  ruptures,  excluding  those  of  the  vagina  or 
cervix,  occurred — that  is,  1  in  3403. 

Seat  of  Rupture. — Lacerations  may  occur  in  any  part  of  the  uterus — 
the  fundus,  the  body,  or  the  cervix.  Those  of  the  cervix  are  compara- 
tively of  small  consequence,  and  occur  to  a  slight  extent  in  almost  all 
first  labors.  Only  those  which  involve  the  supra-vaginal  portion  are  of 
really  serious  import.  Ruptures  of  the  upper  part  of  the  uterus  are 
much  less  frequent  than  of  the  portion  near  the  cervix — partly,  no 
doubt,  because  the  fundus  is  beyond  the  reach  of  the  mechanical  causes 
to  which  the  accident  can,  not  unfrequently,  be  traced,  and  partly  because 
the  lower  third  of  the  organ  is  apt  to  be  compressed  bet^^^een  the  pre- 
senting part  and  the  bony  pelvis.  The  site  of  placental  insertion  is  said 
by  Madame  La  Chapelle  to  be  rarely  involved  in  the  rupture,  but  it 
j does  not  always  escape,  as  numerous  recorded  cases  prove.  The  most 
'frequent  seat  of  rupture  is  near  the  junction  of  the  body  and  neck,  either 
anteriorly  or  posteriorly,  opposite  the  sacrum,  or  behind  the  symphysis 
pubis,  but  it  may  occur  at  the  sides  of  the  lower  segment  of  the  uterus. 
'  In  some  cases  the  entire  cervix  has  been  torn  away  and  separated  in  the 
form  of  a  ring. 

Rupture  may  be  Partial  or  Complete. — The  laceration  may  be  partial 
or  complete,  the  latter  being  the  more  common.  The  muscular  tissue 
alone  may  be  torn,  the  peritoneal  coat  remaining  intact ;  or  the  converse 
may  occur,  and  then  the  peritoneum  is  often  fissured  in  various  direc- 
tions, the  muscular  coat  being  unimplicated.  The  extent  of  the  injury 
is  very  variable,  in  some  cases  being  only  a  slight  tear,  in  others  form- 
ing a  large  aperture,  sufficiently  extensive  to  allow  the  foetus  to  pass  into 
the  abdominal  cavity.  The  direction  of  the  laceration  is  as  variable  as 
the  size,  but  it  is  more  frequently  vertical  than  transverse  or  oblique. 
The  edges  of  the  tear  are  irregular  and  jagged,  probably  on  account  of 
the  contraction  of  the  muscular  fibres,  which  are  frequently  softened, 
infiltrated  with  blood,  and  even  gangrenous.  Large  quantities  of  extrav- 
asated  blood  will  be  found  in  the  peritoneal  cavity,  such  hemorrhage, 
indeed,  being  one  of  the  most  important  sources  of  danger. 

The  causes  are  divided  into  predisposing  and  exciting  ;  aixl  the  prog- 
ress of  modern  research  tends  more  and  more  to  the  conclusion  that  the 
cause  which  leads  to  the  laceration  could  only  have  operated  because  the 
tissue  of  the  uterus  was  in  a  state  predisposed  to  rupture,  and  that  it 
would  have  had  no  such  effect  on  a  perfectly  healthy  organ.  What 
these  predisposing  changes  are,  and  how  they  operate,  is  yet  far  from 
being  known,  and  the  subject  offers  a  fruitful  field  for  pathological 
investigation. 

Said  to  be  more  Common  in  Multipane. — It  is  generally  believed  that 
lacerations  areJmore  common  in  multi  parse  than  in  pri  mi  parse.     Tyler 

^  Rupture  uterine  pendant  le  Travail,  Paris,  1873. 


RUPTURE   OF  THE   UTERUS.  433 

Smith  contended  that  ruptures  are  relatively  as  common  in  first  as  in 
subsequent  labors,  while  Bandl  ^  found  that  only  64  cases  out  of  546 
ruptures  were  in  primiparse.  Statistics  are  not  sufficiently  accurate  or 
extensive  to  justify  a  positive  conclusion,  but  it  is  reasonable  to  suppose 
that  the  pathological  changes  presently  to  be  mentioned  as  predisposing 
to  laceration  are  more  likely  to  be  met  with  in  women  whose  uteri  have 
frequently  undergone  the  alteration  attendant  on  repeated  pregnancies. 
Age  seems  to  have  considerable  influence,  as  a  large  proportion  of  cases 
have  occurred  in  women  between  thirty  and  forty  years  of  age. 

Alterations  in  the  tissues  of  the  uterus  are  probably  of  very  great  import- 
ance in  predisposing  to  the  accident,  although  our  information  on  this  point 
is  far  from  accurate.  Among  these  are  morbid  states  of  the  muscular 
fibres,  the  result  of  blows  and  contusions  during  pregnancy ;  premature 
fatty  degeneration  of  the  muscular  tissues — an  anticipation,  as  it  were, 
oTthe  norniaT  involution  after  delivery ;  fibroid  tumors  or  malignant 
infiltration  of  the  uterine  walls,  which  either  "produce  a  morbid  state  of 
the  tissues  or  act  as  an  impediment  to  the  expulsion  of  the  foetus.  The 
importance  of  such  changes  has  been  specially  dwelt  on  by  Murphy  in 
this  country  and  by  Lehmann  in  Germany,  and  it  is  impossible  not  to 
concede  their  probable  influence  in  favoring  laceration.  However,  as 
yet  these  views  are  founded  more  on  reasonable  hypothesis  than  on  accu- 
rately-observed pathological  facts. 

Another  and  very  important  class  of  predisposing  causes  are  those 
which  lead  to  a  want  of  proper  proportion  between  the  pelvis  and  the 
foetus. 

Deformity  in  Pelvis  is  a  Frequent  Cause. — Deformity  of  the  pelvis  : 
has  been  very  frequently  met  with  in  cases  in  which  the  uterus  has  rup-  I 
tured.  Thus,  out  of  19  cases  carefully  recorded  by  Radford,^  the  pelvis 
was  contracted  in  11,  or  more  than  one-half.  Radford  makes  the  curious 
observation  that  ruptures  seem  more  likely  to  occur  when  the  deformity 
is  only  slight ;  and  he  explains  this  by  supposing  that  in  slight  deformi- 
ties the  lower  segment  of  the  uterus  engages  in  the  brim,  and  is  therefore 
much  subjected  to  compression,  while  in  extreme  deformity  the  os  and 
cervix  uteri  remain  above  the  brim,  the  body  and  fundus  of  the  uterus 
hanging  down  between  the  thighs  of  the  mother.  This  explanation  is 
reasonable,  but  the  rarity  with  which  ruptured  uterus  is  associated  with 
extreme  pelvic  deformity  may  rather  depend  on  the  infrequency  of  ad- 
vanced degrees  of  contraction. 

Views  of  Bandl. — Bandl,  who  has  made  the  most  important  of  mod- 
ern contributions  to  our  knowledge  of  the  subject,  points  out  that  rup- 
ture nearly  always  begins  in  the  lower  segment  of  the  uterus,  which 
becomes  aljnormally  stretched  and  distended  wlien  from  any  cause  the 
expulsion  of  the  foetus  is  delayed.  The  u])per  portion  of  the  uterus 
becomes  at  the  same  time  retracted  and  mu(;h  thickened  (see  Fig.  146). 
As  tlie  pains  continue  the  stretching  of  the  lower  segment  becomes  more 
and  more  marked,  until  at  last  its  fibres  sejiarate  and  a  lacicration  is 
established.  TIk;  line  of  demarcation  between  the  thi(^kencd  Ixxly  and 
the  distended  lower  segment,  known  as  the  ring  of  liandl,  can  in  such 
€ases  be  occasionally  made  out  by  palpation  above  the  [)ubes. 

'  Ueber  Rwplur  der  (ji'.hurmiiUcr,  Wien,  1815.  '■^  Ob^l.  Trtmn.,  vol.  viii. 

28 


434 


LABOR. 


Malpresentation  or  Undue  Size  of  the  Fcefii.s. — Aiiiongst  causes  of  dis- 
proportion depending  on  the  fretus  is  either  malpresentation,  in  Avhich 
the  pains  cannot  effect  expulsion,  or  undue  size  of  the  presenting  part. 
In  the  latter  way  may  be  explained  the  observation  that  rupture  is  more 


Fig.  146. 


Illustrating  the  Dangerous  Thinning  of  the  Lower  Segment  of  Uterus,  owing  to  Non-descent  of 
Head  in  a  Case  of  Intra-uterine  Hydrocephalus.    (After  Bandl.) 

frequently  met  with  in  the  delivery  of  male  than  of  female  children,  on 
account,  no  doubt,  of  the  larger  size  of  the  head  in  the  former.  The 
influence  of  intra-uterine  hydrocephalus  was  first  prominently  pointed 
but  by  Sir  James  Simpson,^  who  states  that  out  of  74  cases  of  intra- 
uterine hydrocephalus,  the  uterus  ruptured  in  16.  In  all  such  cases  of 
disproportion,  whether  referable  to  the  pelvis  or  fcetus,  rupture  is  pro- 
duced in  a  twofold  manner — either  by  the  excessive  and  fruitless  uterine 
contractions,  which  are  induced  by  the  efforts  of  the  organ  to  overcome 
the  obstacle,  or  by  the  compression  of  the  uterine  tissue  between  the  pre- 
senting part  and  the  bony  i)elvis,  leading  to  inflammation,  softening, 
and  even  gangrene. 

Mechanical  Injury. — The  ])roximate  cause  of  rupture  may  be  classed 
under  two  heads — mechanical  injury  and  excessive  uterine  contraction. 
Under  the  former  are  placed  those  uncommon  cases  in  which  the  uterus 
lacerates  as  the  result  of  some  injury  in  the  latter  months  of  pregnancy, 
such  as  blows,  falls,  and  the  like.  Not  so  rare,  unfortunately,  are  lace- 
rations produced  by  unskilled  attempts  at  delivery  on  the  part  of  the 
1  Selected   Ob><t.   WorkM,  p.  385. 


.     •  RUPTURE  OF  THE   UTERUS.  435 

medical  attendant,  such  as  by  the  hand  during  turning  or  by  the  blades 
of  the  forceps.  Many  such  cases  are  on  record  in  which  the  accoucheur 
has  used  force  and  violence  rather  than  skill  in  his  attempts  to  overcome 
an  obstacle.  That  such  unhappy  results  of  ignorance  are  not  so  uncom- 
mon as  they  ought  to  be  is  proved  by  the  figures  of  Jolly,  who  has  col- 
lected 71  cases  of  rupture  during  podalic  version,  37  caused  by  the  for- 
ceps, 10  by  the  cephalotribe,  and  30  during  otlier  operations,  the  precise 
nature  of  which  is  not  stated.^  The  modus  operandi  of  protracted  and 
ineifectual  uterine  contractions,  as  a  proximate  cause  of  rupture,  is  suf- 
ficiently evident,  and  need  not  be  dwelt  on.  It  is  necessary  to  allude, 
however,  to  the  effect  of  ergot,  incautiously  administered,  as  a  producing 
cause.  There  is  abundant  evidence  that  the  injudicious  exhibition  of 
this  drug  has  often  been  followed  by  laceration  of  the  unduly-stimulated 
uterine  fibres.  Thus,  Trask,  talking  of  the  subject,  says  that  Meigs 
had  seen  three  cases,  and  Bedford  four,  distinctly  traceable  to  this  cause. 
Jolly  found  that  ergot  had  been  administered  largely  in  33  cases  in 
which  rupture  occurred. 

Pi'emonitory  Symptoms. — Some  have  believed  that  the  impending 
occurrence  of  rupture  could  frequently  be  ascertained  by  peculiar  pre- 
monitory symptoms,  such  as  excessive  and  acute  crampy  pains  about  the 
lower  part  of  the  abdomen,  due  to  the  compression  of  part  of  the  uterine 
walls.  These  are  far  too  indefinite  to  be  relied  on,  and  it  is  certain  that ' 
the  rupture  generally  takes  place  without  any  symptoms  that  would 
have  afforded  reasonable  grounds  for  suspicion, 

Gene7'al  Symptoms. — The  symptoms  are  often  so  distinct  and  alarm- 
ing as  to  leave  no  doubt  as  to  the  nature  of  the  case.     Not  infrequently, 
however,  especially  if  the  laceration  be  partial,  they  are  by  no  means  so 
well  marked,  and  the  practitioner  nmy  be  uncertain  as  to  what  has  taken 
place.     In  the  former  class  of  cases  a  sudden  excruciating  pain  is  expe- 
rienced  in    the   abdomen,    generally    during   the  uterine  contractions,! 
accompanied  by  a  feeling  on  the  part  of  the  patient  of  something  having  | 
given  way.     In  some  cases  this  has  been  accompanied  by  an  audible'^ 
sound,  which  has  been  noticed  by  the  bystanders.     At  the  same  time 
there  is  generally  a  considerable  escape  of  blood  from  the  vagina,  and  a 
prominent  symptom  is  the  sudden  cessation  of  the  previously  strong 
pains.     Alarming  general  symptoms  soon  develop,  partly  due  to  shock, 
partly  to  loss  of  blood,  both  external  and  internal.     The  face  exhibits  i 
the  greatest  suffering,  the  skin  becomes  deadly  cold  and  covered  with  a  j 
clammy  sweat,  and  fainting,  collapse,  rapid  feeble  pulse,  hurried  breath-  j 
ing,  vomiting,  and  all  the  usual  signs  of  extreme  exhaustion  quickly  1 
follow. 

JiefiulUi  of  Abdominal  and  Vaginal  Examinations. — Abdominal  pal- 
pation and  vaginal  examination  both  afford  characteristic  indications  in 
well-marked  cases.  If  the  child,  as  often  happens,  has  escaped  entirely 
or  in  great  part  into  the  abdominal  cavity,  it  may  be  readily  felt 
through  the  abdominal  walls;  while  in  the  former  case  the  partially- 
contracted  uterus  may  Ik;  foiuid  se]);iratc  from  it  in  iha  form  of  a  glob- 
ular tumor  resembling  the  ut(M-us  aftcT  (hilivery.  Per  vnginani  it  may 
generally  be  ascertained  that  the  presenting  |)art  has  suddenly  receded 

'  Op.  cil.,  [).  :58. 


436  LABOR. 

and  can  no  longer  be  made  out,  or  some  other  part  of  the  foetus  may  be 
found  in  its  pkice.  If  the  rupture  be  extensive,  it  may  be  appreciable 
on  vaginal  examination,  and  sometimes  a  loop  of  intestine  may  be  found 
protruding  through  the  tear.  Other  occasional  signs  have  been 
recorded,  such  as  an  emphysematous  state  of  the  lower  part  of  the 
abdomen,  resulting  from  the  entrance  of  air  into  the  cellular  tissue,  or 
the  formation  of  a  sanguineous  tumor  in  the  liypogastrium  or  vagina. 
These  are  too  uncommon  and  too  vague  to  be  of  much  diagnostic  value. 
Symptoms  are  Sometimes  Obscure. — Unfortunately,  the  symptoms  are 
by  no  means  always  so  distinct,  and  cases  occur  in  which  most  of  the 
reliable  indications,  such  as  the  sudden  cessation  of  the  pains,  the  exter- 
nal hemorrhage,  and  the  retrocession  of  the  presenting  part,  may  be 
absent.  In  some  cases,  indeed,  the  symptoms  have  been  so  obscure  that 
the  real  nature  of  the  case  has  only  been  detected  after  death.  It  is 
rarely,  however,  that  the  occurrence  of  shock  and  prostration  is  not  suf- 
ficiently distinct  to  arouse  suspicion,  even  in  the  absence  of  the  usual 
marked  signs.  In  not  a  few  cases  distinct  and  regular  contractions  have 
gone  on  after  laceration,  and  the  child  has  even  been  born  in  the  usual 
way.  Of  course  in  such  a  case  mistake  is  very  possible.  So  curious  a 
circumstance  is  difficult  of  explanation.  The  most  probable  way  of 
accounting  for  it  is  that  the  laceration  has  not  implicated  the  fundus  of 
the  uterus,  which  contracted  sufficiently  energetically  to  expel  the  foetus. 
Hence  it  will  be  seen  that  the  symptoms  are  occasionally  obscure,  and 
the  practitioner  must  be  careful  not  to  overlook  the  occurrence  of  so  seri- 
ous an  accident  because  of  the  absence  of  the  usual  and  characteristic 
symptoms. 

'i      Prognosis. — The  prognosis  is  necessarily  of  the  gravest  possible  cha- 
*racter,  but  modern  views  as  to  treatment  perhaps  justify  us  in  saying 
that  it  is  not  so  absolutely  hopeless  as  has  been  generally  taught  in  our 
obstetric  works.. 

To  the  Mother. — When  we  reflect  on  what  has  occurred — the  profound 
nervous  shock  ;  the  profuse  hemorrhage,  both  external,  and  especially 
into  the  peritoneal  cavity,  where  the  blood  coagulates  and  forms  a  for- 
eign body ;  the  passage  of  the  uterine  contents  into  the  abdomen,  with 
the  inevitable  result  of  inflammation  and  its  consequences  if  the  patient 
survive  the  primary  shock, — the  enormous  fatality  need  cause  no  sur- 
prise. Jolly  has  found  that  out  of  580  cases  100  recovered — that  is,  in 
the  proportion  of  1  out  of  6.  This  is  a  far  more  favorable  result  than 
we  are  generally  led  to  anticipate ;  and  as  many  of  the  recoveries  hap- 
pened in  apparently  the  most  desperate  and  unfavorable  cases,  we  should 
learn  the  lesson  that  we  need  not  abandon  all  hope,  and  should  at  least 
endeavor  to  rescue  the  patient  from  the  terrible  dangers  to  which  she  is 
exposed. 

To  the  Child. — As  regards  the  child,  the  prognosis  is  almost  necessarily 
fatal ;  and,  indeed,  the  cessation  of  the  foetal  heart-sounds  has  been 
pointed  out  by  McClintock  as  a  sign  of  rupture  in  doubtful  cases.  The 
shock,  the  profuse  hemorrhage,  and  the  time  that  must  necessarily  elaj)se 
before  the  delivery  of  the  child  are  of  themselves  quite  sufficient  to 
explain  the  fact  that  the  foetus  is  almost  always  dead. 

Treatment. — From  what  has  been  said  of  the  impossibility  of  fore- 


RUPTURE  OF  THE   UTERUS.  437 

telling  the  occurrence  of  rupture,  it  must  follow  that  no  reliable  prophy- 
lactic treatment  can  be  adopted  beyond  that  which  is  a  matter  of  general 
obstetric  principle — viz.  timely  interference  when  the  uterine  contractions 
seem  incapable  of  overcoming  an  obstacle  to  delivery,  either  on  the  part 
of  the  pelvis  or  foetus. 

Indications  offer  Rupture  has  Taken  Place. — After  rupture  the  main 
indications  are  to  effect  the  removal  of  the  child  and  the  placenta,  to 
rally  the  patient  from  the  effects  of  the  shock,  and,  if  she  survives  so 
long,  to  combat  the  subsequent  inflammation  and  its  consequences.  By 
far  the  most  important  point  to  decide  is  the  best  means  to  be  adopted 
for  the  removal  of  the  child ;  for  it  is  admitted  by  all  that  the  hopeless 
expectancy  that  was  recommended  by  the  older  accoucheurs — or,  in  other 
words,  allowing  the  patient  to  die  without  making  any  effort  to  save 
her — is  quite  inadmissible.  If  the  foetus  be  entirely  within  the  uterine 
cavity,  no  doubt  the  proper  course  to  pursue  is  to  deliver  at  once  per  vias 
naturales,  either  by  turning,  by  forceps,  or  by  cephalotripsy.  If  any . 
part  other  than  the  head  present,  turning  will  be  best,  great  care  being 
taken  to  avoid  further  increase  of  the  laceration.  If  the  head  be  in  the 
cavity  or  at  the  brim  of  the  pelvis,  and  within  easy  reach  of  the  forceps, 
it  may  be  cautiously  applied,  the  child  being  steadied  by  abdominal 
pressure  so  as  to  facilitate  its  application.  If  there  be,  as  is  often  the 
case,  some  slight  amount  of  pelvic  contraction,  it  may  be  preferable  to 
perforate  and  apply  the  cephalotribe,  so  as  to  avoid  any  forcible  attempts 
at  extraction,  which  might  unduly  exhaust  the  already  prostrate  patient 
and  turn  the  scale  against  her.  This  will  be  the  more  allowable  since 
the  child  is,  as  we  have  seen,  almost  always  dead,  and  we  might  readily 
ascertain  if  it  be  so  by  auscultation. 

Removal  of  the  Placenta. — After  delivery  extreme  care  must  be  taken 
in  removing  the  placenta,  and  for  this  it  will  be  necessary  to  introduce 
the  hand.  The  placenta  will  generally  be  in  the  uterus,  for  if  the  rent 
be  not  large  enough  for  the  child  to  pass  through,  it  may  be  inferred  that 
the  placenta  will  not  have  done  so  either.  If  it  has  escaped  from  the 
uterus,  very  gentle  traction  on  the  cord  may  bring  it  within  reach  of  the 
hand,  and  so  the  passage  of  the  hand  through  the  tear  to  search  for  it 
will  be  avoided. 

Treatment  tvhen  the  Foetus  has  Escaped  out  of  the  Uterits. — There  can 
be  but  little  doubt  that  in  the  cases  indicated  such  is  the  proper  treat- 
ment and  that  which  affords  the  mother  the  best  chance.  Unfortunately, 
the  cases  in  which  the  child  remains  entirely  in  utero  are  comparatively 
uncommon,  and  generally  it  will  have  escaped  into  the  abdomen,  along 
with  much  extra vasated  blood.  The  usual  plan  of  treatment  recom- 
mended under  such  circumstances  is  to  pass  the  hand  through  the 
fissure  (some  have  even  recommended  that  it  should  be  enlarged  by 
incision  if  necessary),  to  seize  the  feet  of  the  fcjetus,  to  drag  it  back 
tliroiigh  the  torn  uterus,  and  then  to  reintroduce  the  hand  to  search  for 
and  n^rnove  the  placenta.  Imagine  what  occurs  dnrinjf  the  ]W)Ccss  ! 
The  hand  gropes  blindly  among  the  abdonn'nal  viscera,  the  f()r('il)le 
<lragging  l)ack  of  the  fxitus  necessarily  tears  the  uterus  more  and  more, 
and,  above  all,  the  extravasated  blood  remains  as  a  foreign  body  in  the 
peritoneal  (^vity,  and  necessarily  gives  rise  to  the  nujst  serious  conse- 


438 


LABOR. 


quences.  It  is  surely  hardly  a  matter  of  surprise  that  there  is  scarcely 
a  single  case  on  record  of  recovery  after  this  procedure. 

Reasons  ivhy  Gastrotomy  affords  a  Better  Chance  of  Success. — Of  late 
years  a  strong  feeling  lias  existed  that  whenever  the  child  has  entirely 
or  in  great  part  escaped  into  the  abdominal  cavity  the  operation  of  gas- 
trotomy aifords  the  mother  a  tar  better  chance  of  recovery ;  and  it  has 
now  been  performed  in  many  cases  with  the  most  encouraging  results. 
It  is  easy  to  see  why  the  prospects  of  success  are  greater.  The  uterus 
being  already  torn  and  the  peritoneum  opened,  the  only  additional  dan- 
ger is  the  incision  of  the  abdominal  parietes,  M'hich  gives  us  the  o])})or- 
t unity  of  sponging  out  the  peritoneal  cavity,  as  in  ovariotomy,  and  of 
removing  all  the  extravasated  blood,  the  retention  of  which  so  seriously 
adds  to  the  dangers  of  the  case.  Another  advantage  is  that,  if  the 
patient  be  excessively  prostrate,  the  operation  may  be  delayed  until  she 
has  somewhat  rallied  from  the  effects  of  the  shock,  whereas  delivery  by 
the  feet  is  generally  resorted  to  as  soon  as  the  rupture  is  recognized  and 
when  the  patient  is  in  the  worst  possible  condition  for  interference  of  any 
kind. 

Comparative  Results  of  Various  Methods  of  Treatment. — Jolly  has 
carefully  tabulated  the  results  of  the  various  methods  of  treatment,  and, 
making  every  allowance  for  the  unavoidable  errors  of  statistics,  it  seems 
beyond  all  question  that  the  results  of  gastrotomy  are  so  greatly  superior 
to  those  of  othef  plans  that  I  think  its  adoption  may  fairly  be  laid  down 
as  a  rule  whenever  the  foetus  is  no  longer  within  the  uterine  cavity  : 

Comparative  Eesults  of  Various  Methods  of  Treatment  after  Eupture 

OF  Uterus. 


Treatment. 


Expectation 

Extraction  per  vias  naiurales 
Gastrotomy 


No.  of 
Cases. 

Deaths. 

144 

382 
38 

142 

310 

12 

Recoveries. 


2 

72 
26 


Per  cent,  of 
Recoveries. 


1.45 
19 
68.4 


Of  course  this  table  will  not  justify  the  conclusion  that  68  per  cent, 
of  the  cases  of  ruptured  uterus  in  which  gastrotomy  is  performed  will 
recover ;  but  it  may  fairly  be  taken  as  proving  that  the  chances  of 
recovery  are  at  least  three  or  four  times  as  great  as  when  the  more  usual 
practice  is  adopted. 

\_American  Puerperal  Laparotomies. — After  a  search  of  several  years 
I  have  thus  far  collected  43  cases  in  the  United  States,  with  21  women 
and  2  children  saved.  One  mother  and  child  were  saved  by  an  imme- 
diate operation  with  a  pocket-knife  in  1869.  I  presume  that  a  general 
record  of  American  operations,  published  and  unpublished,  would  show 
a  saving  of  nearly  50  per  cent.,  Avhich  is  much  loAver  than  that  claimed 
by  Trask  and  Jolly,  collected  from  published  reports.  Take  Trask's 
foreign  cases,  20,  and  our  own  43,  and  we  have,  native  and  foreign,  63, 
with  37  recoveries  and  26  deaths.  I  look  upon  our  own  statistics  as 
much  more  reliable,  because  many  of  the  unpublished  cases  were  searched 
out  by  correspondence. — Ed.] 


RUPTURE  OF  THE   UTERUS.  439 

Lacerations  of  the  Cervix. — Lacerations  of  the  cervix  are  of  very 
common  occurrence.  Occasionally,  after  delivery,  they  may  cause  hem- 
orrhage when  the  uterus  itself  is  firmly  contracted,  or  secondary  hemor- 
rhage during  the  puerperal  month.  As  a  rule,  they  are  not  recognized, 
and  it  is  only  of  late  years,  chiefly  owing  to  the  labors  of  Emmet,  that 
this  important  influence  in  producing  various  chronic  forms  of  uterine 
disease  has  been  realized.  In  the  large  majority  of  cases  the  lacerations 
are  lateral,  either  on  one  or  both  sides  of  the  cervix.  If  they  give  rise 
to  hemorrhages,  the  local  application  of  styptics  is  probably  the  best 
resource.  Whether  it  is  advisable  to  treat  severe  forms  by  the  imme- 
diate application  of  silver  sutures,  as  recommended  by  Fallen,^  is  a  sub- 
ject as  yet  too  little  understood  to  justify  the  expression  of  an  opinion. 

Necessity  of  Care  in  Performing  the  Operation. — It  is  perhaps  needless 
to  say  that  the  operation  must  be  performed  with  the  same  minute  care 
that  has  raised  ovariotomy  to  its  present  pitch  of  perfection,  and  that 
especial  attention  should  be  paid  to  the  sponging  out  of  the  peritoneum, 
and  the  removal  of  foreign  matters. 

Recapitulation. — To  recapitulate,  I  think  what  has  been  said  justifies 
the  following  rules  of  treatment  after  rupture : 

1.  If  the  head  or  presenting  part  be  above  the  brim  and  the  foetus 
still  in  utero — forceps,  turning,  or  cephalotripsy,  according  to  circum- 
stances. 

2.  If  the  head  be  in  the  pelvic  cavity — forceps  or  cephalotripsy. 

3.  If  the  foetus  have  wholly  or  in  great  part  escaped  into  the  abdomi- 
nal cavity — gastrotomy. 

Subsequent  Treatment. — As  to  the  subsequent  treatment  little  need  be 
said,  since  in  this  we  must  be  guided  by  general  principles.  The  chief 
indication  will  be  to  remove  shock  and  rally  the  patient  by  stimulants, 
etc.,  and  to  combat  secondary  results  by  opiates  and  other  appropriate 
remedies. 

Lacerations  of  the  vagina  occasionally  take  place,  and  in  the  great 
majority  of  cases  they  are  produced  by  instruments,  either  from  a  want 
of  care  in  their  introduction  or  from  undue  stretching  of  the  vaginal 
walls  during  extraction  with  the  forceps.  Slight  vaginal  lacerations  are 
probably  much  more  common  after  forceps  delivery  than  is  generally 
believed  to  be  the  case.  As  a  rule,  they  are  productive  of  no  permanent 
injury,  although  it  must  not  be  forgotten  that  every  breach  of  continuity 
increases  the  risk  of  subsequent  septic  absorption.  When  the  laceration 
is  sufficiently  deep  to  tear  through  the  recto-vaginal  septum  or  the 
anterior  vaginal  wall,  the  passage  of  the  urine  or  feces  is  apt  to  prevent 
its  edges  uniting ;  then  that  most  distressing  condition,  recto-vaginal  or 
vesico-vaginal  fistula,  is  established. 

Fistulm  are  Seldom  Caused  by  Mechanical  Injury. — It  must  not  be 
supposed  that  fistulse  are  often  the  result  of  injury  during  operative 
interference.  That  is  a  common  but  very  erroneous  opinion  both  among 
tlie  jirofession  and  the  public.  In  the  vast  majority  of  (^ascs  the  fistu- 
lous ()|)eniiig  is  the  coiisequeiico  of  a  slough  resulting  from  inflammation, 
pi-()(liiff(l  by  loiig-coiilimu'd  pressure  of  tlu;  vaginal  walls  l)etvv('en  the 
child's  head  and  llic  bony  jK-lvis  in  cases  in  which  the  second  stage  has 

'  'rrfinmcllonn  of  the  Tnlern.  Med.  Congr.,  v.  4. 


440  LABOR. 

been  allowed  to  go  on  too  long.  In  most  of  these  cases  instruments 
were  doubtless  eventually  used,  and  they  get  the  blame  of  the  accident ; 
whereas  the  fault  lay,  not  in  their  being  employed,  but  rather  in  their 
not  having  been  used  soon  enough  to  prevent  the  contusion  and  inflam- 
mation which  ended  in  sloughing. 

Proof  of  this  Statement. — AVhen  vesico-vaginal  fistulse  are  the  result 
of  lacerations  during  labor,  the  urine  must  escape  at  once,  but  this  is 
rarely  the  case.  In  the  large  majority  of  cases  the  urine  does  not  pass 
per  vaginam  until  more  than  a  week  after  delivery,  showing  that  a  lapse 
of  time  is  necessary  for  inflammatory  action  to  lead  to  sloughing.  In 
order  to  throw  some  light  on  these  points,  on  which  very  erroneous 
views  have  been  held,  I  have  carefully  examined  the  histories,  from 
various  sources,  of  63  cases  of  vesico-vaginal  fistula. 

1st.  In  20  no  instruments  were  employed.  Of  these,  there  were  in 
labor — 

Under  24  hours 2 

From  24  to  48  hours 8  ^ 

"      48  to  70     ''       2 

"      70  to  80     "       7 

"      80  hours  and  upward      1 

20 

Therefore,  out  of  these  20  cases,  one-half  were  certainly  more  than  48 
hours  in  labor,  and  6  of  the  remaining  10  were  probably  so  also.  In 
only  1  of  them  is  the  urine  stated  to  have  escaped  per  vaginam  immedi- 
ately after  delivery.  In  7  it  is  said  to  have  done  so  within  a  week,  and 
in  the  remainder  after  the  seventh  day. 

2d.  In  34  cases  instruments  were  used,  but  there  is  no  evidence  of 
their  having  produced  the  accident.     Of  these,  there  were  in  labor — 

Under  24  hours 2 

From  24  to  48  hours 8 

"      48  to  72     "  10 

"     72  hours  and  upward _lj4 

"34 

The  urine  escaped  within  24  hours  in  2  cases  only,  within  a  week  in  16, 
and  after  the  seventh  day  in  15.  So  that  here,  again,  we  have  the  his- 
tory of  unduly-protracted  delivery,  24  out  of  the  34  having  been  cer- 
tainly more  than  48  hours  in  labor. 

3d.  In  9  cases  the  histories  show  that  the  production  of  the  fistula 
may  fairly  be  ascribed  to  the  unskilled  use  of  instruments.  Of  these, 
there  were  in  labor — 

Under  24  hours 7 

From  24  to  48  hours 1 

"      48  to  72     "  _L 

9 

The  urine  escaped  at  once  in  7  cases,  and  in  the  remaining  2  after  the 
seventh  day. 

1  But  of  these,  in  7  no  precise  time  is  stated.  6  of  them  are  marked  very  tedious, 
therefore  they  probably  exceeded  the  limit. 


RUPTURE  OF  THE   UTERUS.  441 

These  statistics  seem  to  me  to  prove,  in  the  clearest  manner,  that  in 
the  hirge  majority  of  cases  this  unhappy  accident  may  be  directly  traced 
to  the  bad  practice  of  allowing  labor  to  drag  on  many  hours  in  the  sec- 
ond stage  without  assistance,  and  not  to  premature  instrumental  interfe- 
rence. This  question  has  recently  been  elaborately  studied  by  Emmet, 
who  gives  numerous  statistical  tables  which  fully  corroborate  these  views. 
His  conclusion,  the  result  of  much  practical  experience  of  vesico-vaginal 
fistulse,  is  worthy  of  being  quoted.  "  I  do  not  hesitate,"  he  says,  "  to 
make  the  statement  that  I  have  never  met  with  a  case  of  vesico-vaginal 
fistula  which  without  doubt  could  be  shown  to  have  resulted  from 
instrumental  delivery.  On  the  contrary,  the  entire  weight  of  evidence 
is  conclusive  in  showing  that  the  injury  is  a  consequence  of  delay  in 
delivery."  ^ 

Treatment. — As  to  the  treatment  of  vaginal  laceration,  little  can  be 
said.  In  the  slighter  cases  vaginal  injections  of  diluted  Condy's  fluid 
will  be  useful  to  lessen  the  risk  of  septic  absorption ;  and  the  graver, 
when  vesico-vaginal  or  recto-vaginal  fistulse  have  actually  formed,  are 
not  within  the  domain  of  the  obstetrician,  but  must  be  treated  surgically 
at  some  future  elate. 

l^The  Rational  Treatment  of  Rupture  of  the  Uterus. — The  three  rules 
given  on  page  439  are  those  found  in  obstetrical  works  of  high  author- 
ity, but  are  not  based  upon  the  teachings  of  abdominal  surgery  as  shown 
by  the  results  of  operations  recorded  within  a  few  years.  Reasoning 
from  analogy  and  the  fearful  mortality  of  cases  delivered  i^er  vias  nat- 
urales  after  uterine  rupture,  we  are  forced  to  the  conclusion  that  some- 
thing more  is  needed  than  the  delivery  of  the  woman  and  the  removal 
of  the  placenta  if  we  hope  to  reduce  the  proportion  of  deaths,  which  is 
very  great  except  after  laparotomy — a  method  of  delivery  capable  of 
saving  nearly  50  per  cent.  There  is  no  objection  to  delivering  the  foetus 
by  the  natural  channel,  provided  it  can  be  readily  done ;  but  we  have 
very  little  reason  to  anticipate  a  favorable  result  if  we  rest  our  eiforts 
here.  Children  entirely  escaped  into  the  abdominal  cavity  have  been 
drawn  back  through  the  rent  and  delivered  by  the  vagina,  and  the 
women  have  recovered.  In  one  well-authenticated  case  the  woman  was 
thus  saved  in  our  own  country  on  four  occasions.  But  we  are  not  to 
expect  such  results,  as  a  fatal  issue  is  far  more  frequent  than  a  recovery 
under  such  circumstances.  Our  object  should  be  to  save  the  life  of  the 
mother  and,  if  at  all  possible,  that  of  the  foetus ;  and  all  our  eiforts 
sliould  be  directed  to  this  end.  We  may  console  ourselves  with  having 
delivered  the  woman  prior  to  her  death,  but  to  prevent  this  fatal  issue 
slujuld  be  our  chief  aim.  The  general  impression  among  ovariotoraists 
is,  tliat  blood  is  not  an  innocent  fluid  in  the  abdominal  cavity ;  and  the 
remarkable  results  of  the  operations  of  Dr.  Keitli  of  Edinburgh  are 
attributed  to  the  care  he  exercises  in  preventing  tlie  secondary  escape 
of  blood  into  the  abdominal  cavity.  Dr.  Ivudwig  Winckcl  of  Miillieim, 
Ocrmaiiy,  who  performed  th(;  (Jsesarean  ojKM-ation  l.'>  tim(!S  and  laparo- 
tomy after  ru])tiire  of  the  uterus  4  times,  was  of  the  inij)ression  that  the 
li(|Uor  aniiiii  was  innocuous  if  only  a  short  time  in  contact  with  the 
peritoneum  ;  and  tlx;  same  may  Ik;  said  of  blood,  ovarian  fluid,  parova- 

'   The  PrinciplfK  mid  Piarllce  of  (,'i/ii(i'riiliiiji/,  \i.  (idiJ. 


442  LABOR. 

rian  fluid,  and,  to  some  degree,  also  of  urine.  Rupture  of  the  bladder  is 
now  cured  by  sewing  up  the  rent  and  carefully  cleansing  the  abdominal 
cavity  of  blood  and  urine.  But  these  fluids  are  all  capable  of  setting  up 
peritonitis,  and  blood  by  its  decomposition  is  particularly  apt  to  give 
rise  to  septic  poisoning :  then  why  let  it  remain  in  the  abdominal  cavity 
in  cases  of  ruptured  uterus?  If  it  is  important  to  cleanse  this  cavity 
from  blood  and  ovarian  fluid  in  ovariotomy,  and  from  blood  and  amni- 
otic fluid  after  the  Cses'arean  section,  then  why  should  we  be  content 
with  delivering  the  foetus  in  cases  of  rupture  of  the  uterus,  when  we 
know  that  the  peritoneal  cavity  still  contains  a  compound  fluid  which 
may  destroy  the  woman  if  not  removed  and  the  jiarts  cleansed  ?  We 
have  also  an  additional  risk  in  the  fact  that  the  uterine  rupture  may 
gape  and  allow  the  lochia  to  escape  into  the  peritoneal  cavity,  thus  pro- 
viding another  element  for  septic  poisoning.  I  am,  then,  fully  per- 
suaded that  in  all  cases  of  rupture,  where  it  is  evident  that  blood  and 
liquor  amnii  have  escaped  into  the  abdominal  cavity,  we  ought  to  open 
the  abdomen,  cleanse  out  the  cavity,  and  close  the  rent  by  deep-seated 
and  superficial  sutures  of  silver  wire  or  carbolized  pure  silk.  In  cer- 
vico-vaginal  rupture  the  closure  of  the  rent  may  not  be  so  important  in 
the  sense  of  safety  to  the  woman,  as  there  is  generally  a  natural  drain- 
age into  the  vagina ;  neither  is  laparotomy  itself  so  imperatively 
demanded  as  in  cases  where  the  fundus  or  body  of  the  uterus  is  rent. 
But  it  becomes  important  to  close  the  rent  cervix  in  view  of  future 
trouble  from  ectropium  and  erosion.  As  in  the  Csesarean  operation, 
promptness  of  action  is  all  important  if  we  hope  to  save  the  patient.  I 
know  that  these  views  upon  the  treatment  of  ruptured  uterus  are  in 
advance  of  those  held  by  British  obstetrical  writers,  but  they  are  cer- 
tainly logical  deductions  from  the  experience  of  such  operators  as  Dr. 
Keith,  Mr.  Lawson  Tait,  and  others,  and  from  the  well-known  results 
of  promptly-performed  laparotomies  in  rupture  accidents  in  the  United 
States.  The  removal  of  the  uterus  after  rupture  has  as  yet  only  added 
to  the  risk,  and  I  do  not  believe  we  are  justified  in  resorting  to  it  where 
there  is  no  pelvic  obstruction. — Ed.] 


CHAPTER   XVII. 

INVEESION  OF  THE  UTEEUS. 

Its  Formidable  Character. — Inversion  of  the  uterus  shortly  after  the 
birth  of  the  child  is  one  of  the  most  formidable  accidents  of  parturition, 
leading  to  symptoms  of  the  greatest  urgency,  not  rarely  proving  fatal, 
and  requiring  prompt  and  skilful  treatment.  Hence  it  has  obtained  an 
unusual  amount  of  attention,  and  there  are  few  obstetric  subjects  which 
have  been  more  carefully  studied. 

An  Accident  of  Great  Rarity. — Fortunately,  the  accident  is  of  great 


INVERSION   OF  THE    UTERUS. 


443 


Fig.  147 


rarity.  It  was  only  observed  once  in  upward  of  190,800  deliveries  at 
the  Rotunda  Hospital  since  its  foundation  in  1745,  and  many  prac- 
titioners have  conducted  large  midwifery  practices  for  a  lifetime  without 
ever  having  witnessed  a  case.  It  is  none  the  less  needful,  however,  that 
we  should  be  thoroughly  acquainted  with  its  natural  history  and  with 
the  best  means  of  dealing  with  the  emergency  when  it  arises. 

Division  into  Acute  and  Ohronic  Forms. — Inversion  of  the  uterus 
may  be  met  with  in  the  acute  or  chronic  form ;  that  is  to  say,  it  may 
come  under  observation  either  immediately  or  shortly  after  its  occurrence, 
or  not  until  after  a  considerable  lapse  of  time,  when  the  involution  fol- 
lowing pregnancy  has  been  completed.  The  latter  falls  more  properly 
under  the  province  of  the  gynaecologist,  and  involves  the  consideration 
of  many  points  that  would  be  out  of  place  in  a  work  on  obstetrics.  Here, 
therefore,  the  acute  form  alone  is  considered. 

Description  of  Inversion. — Inversion  consists  essentially  in  the  en- 
larged and  empty  uterus  being  turned  inside  out,  either  partially  or 
entirely ;  and  this  may  occur  in  various  de- 
grees, three  of  which  are  usually  described 
and  are  practically  useful  to  bear  in  mind. 
In  the  first  and  slightest  degree  there  is 
merely  a  cup-shaped  depression  of  the  fun- 
dus (Fig.  147) ;  in  the  second  the  depres- 
sion is  greater,  so  that  the  inverted  portion 
forms  an  intro-susception,  as  it  were,  and 
projects  downward  through  the  os  in  the 
form  of  a  round  ball,  not  unlike  the  body 
of  a  polypus,  for  which,  indeed,  a  careless 
observer  might  mistake  it ;  and,  thirdly, 
there  is  the  complete  variety,  in  which  the 
whole  organ  is  turned  inside  out,  and  may 
even  project  beyond  the  vulva. 

Its  Symptoms. — The  symptoms  are  gen- 
erally very  characteristic,  although  when 
the  amount  of  inversion  is  small  they  may 
entirely  escape  observation.  They  are 
chiefly  those  of  profound  nervous  shock 
— viz.  fainting,  small,  rapid,  and  feeble 
pulse,  possibly  convulsions  and  vomiting, 
and  a  cold  clammy  skin.  Occasionally  severe  abdominal  pain  and  cramp 
and  l)earing-down  are  felt.  Hemorrhage  is  a  frequent  accompaniment, 
Sfjmotimes  to  a  very  alarming  extent,  especially  if  the  placenta  be  par- 
tially or  entirely  detached.  The  loss  of  blood  depends  to  a  great  extent 
on  the  condition  of  the  uterine  parietes.  If  there  be  much  contraction 
on  the  part  tliat  is  not  inverted,  the  intro-suscepted  part  may  be  suf- 
ficiently (;oni[)ressed  to  prevent  any  great  loss.  If  the  entire  organ  be 
in  a  state  of  relaxation,  the  loss  may  be  excessive. 

liesidts  of  Pliysical  ExMminatlon. — The  occurrence  of  sucli  symptoms 
shortly  after  delivery  would  of  necessity  lead  to  an  acciurate  examination, 
when  the  nature  of  the  case  may  be  at  once  ascertained.  On  passing 
the  fingc^r  into  the  vagina  we  cither  find  the  entire  ntei-us  forming  a  glob- 


Partial  Inversion  of  the  Fundus. 

(From  a  preparation  in  the  Museum  of 

Guy's  Hospital.) 


444  LABOR. 

ular  mass,  to  which  the  placenta  is  often  attached,  or,  if  the  inversion 
be  incomplete,  the  vagina  is  occupied  by  a  firm,  round,  and  tender  swell- 
.  ing  which  can  be  traced  upward  through  the  os  uteri.  The  hand  placed 
on  the  abdomen  will  detect  the  absence  of  the  round  ball  of  the  con- 
tracted uterus,  and  bi-manual  examination  may  even  enable  us  to  feel 
the  cup-shaped  depression  at  the  site  of  inversion. 

Differential  Diagnosis. — When  such  signs  are  observed  immediately 
after  delivery  mistake  is  hardly  possible.  Numerous  instances,  however, 
are  recorded  in  which  the  existence  of  inversion  was  not  immediately 
detected,  and  the  tumor  formed  by  it  only  observed  after  the  lapse  of 
several  days,  or  even  longer,  when  the  general  symptoms  led  to  vaginal 
examination.  It  is  probable  that  in  such  cases  a  partial  inversion  had 
taken  place  shortly  after  delivery,  which  as  time  elapsed  became  grad- 
ally  converted  into  the  more  complete  variety.  In  a  case  of  this  kind, 
as  in  a  chronic  inversion,  some  care  is  necessary  to  distinguish  the  inver- 
sion from  a  uterine  polypus,  which  it  closely  resembles.  The  cautious 
insertion  of  the  sound  will  render  the  diagnosis  certain,  since  its  passage 
is  soon  arrested  in  inversion,  while  if  the  tumor  be  jjolypoid  it  readily 
passes  in  as  far  as  the  fundus. 

Manner  in  which  Inversion  is  Produced. — The  mechanism  by  which 
inversion  is  produced  is  well  worthy  of  study,  and  has  given  rise  to 
much  diflPerence  of  opinion. 

Occasionally  Produced  by  Accidental  Mechanical  Causes. — A  very 
general  theory  is  that  it  is  caused  in  many  cases  by  mismanagement  of 
the  third  stage  of  labor,  either  by  traction  on  the  cord,  the  placenta 
being  still  adherent,  or  by  improperly-applied  pressure  on  the  fundus ; 
the  result  of  both  these  errors  being  a  cup-shaped  depression  of  the  fun- 
dus, which  is  subsequently  converted  into  a  more  complete  variety  of 
inversion.  That  such  causes  may  suffice  to  start  the  inversion  cannot 
be  doubted,  but  it  is  probable  that  their  frequency  has  been  much  exag- 
gerated. Still,  there  are  numerous  recorded  cases  in  which  the  com- 
mencement of  the  inversion  can  be  traced  to  them.  Improperly-applied 
pressure  (as  when  the  whole  body  of  the  uterus  is  not  grasped  in  the 
hollow  of  the  hand,  but  when  a  monthly  nurse  or  other  uninstructed 
person  presses  on  the  lower  part  of  the  abdomen  so  as  simply  to  juisli 
down  the  uterus  en  masse)  is  often  mentioned  in  liistories  of  the  accident. 
Thus,  in  the  Edinburgh  3Iedical  Journcd  for  June,  1848,  a  case  is  related 
in  which  the  patient  w^ould  not  have  a  medical  man,  but  was  attended 
by  a  midwife,  Avho  after  the  birth  of  the  child  pulled  on  the  cord,  while 
the  patient  herself  clasped  her  hands  and  pushed  down  her  abdomen,  at 
the  same  time  straining  forcibly,  when  the  uterus  became  inverted  and 
the  patient  died  of  hemorrhage  before  assistance  could  be  procured. 
Here  both  of  the  mechanical  causes  mentioned  were  in  operation.  In 
several  cases  it  is  mentioned  that  the  accident  occurred  ^\hile  the  nurse 
was  compressing  the  abdomen.  That  the  accident  is  practically  impos- 
sible when  firm  and  equable  contraction  has  taken  place  cannot  be  ques- 
tioned. Hence  it  is  of  paramount  importance  that  the  practitioner  should 
himself  carefully  attend  to  the  conduct  of  the  third  stage  of  labor. 

Often  Occurs  Spontaneously. — In  a  large  proportion  of  cases  no 
mechanical  causes  can   be  traced,  and  the  occurrence  of  spontaneous 


INVERSION  OF  THE   UTERUS.  445 

inversion  must  be  admitted.  There  are  various  theories  held  as  to 
how  this  occurs.  Partial  and  irregular  contraction  of  the  uterus  is 
generally  admitted  to  be  an  important  factor  in  its  production ;  but  it 
is  still  a  matter  of  dispute  whether  the  inversion  is  produced  mainly  by 
an  active  contraction  of  the  fundus  and  body  of  the  uterus,  the  lower 
portion  and  cervix  being  in  a  state  of  relaxation,  or  whether  the  precise 
reverse  of  this  exists,  the  fundus  being  relaxed  and  in  a  state  of  quasi- 
paralysis,  while  the  cervix  and  lower  portion  of  the  uterus  are  irregu- 
larly contracted.  The  former  is  the  view  maintained  by  Radford  and 
Tyler  Smith,  while  the  latter  is  upheld  by  Matthews  Duncan. 

Evidence  in  Favor  of  Duncan's  Theory. — There  are  good  clinical 
reasons  for  believing  that  Duncan's  view  more  nearly  corresponds  with 
the  true  facts  of  the  case ;  for  if  the  fundus  and  body  of  the  uterus  be 
really  in  a  state  of  active  contraction  while  the  cervix  is  relaxed,  we 
have,  as  Duncan  points  out,  the  very  condition  which  is  normal  and 
desirable  after  delivery,  and  that  which  we  do  our  best  to  produce.  If, 
however,  the  opposite  condition  exist  and  tlie  fundus  be  relaxed,  while 
the  lower  portion  is  spasmodically  contracted,  a  state  exists  closely  allied 
to  the  so-called  hour-glass  contraction.  Supposing  now  any  cause  pro- 
duces a  partial  depression  of  the  fundus,  it  is  easy  to  understand  how  it 
may  be  grasped  by  the  contracted  portion  and  carried  more  and  more 
down,  in  the  manner  of  an  intro-susception,  until  complete  inversion 
results.  That  such  partial  paralysis  of  the  uterine  walls  often  exists, 
especially  about  the  placental  site,  was  long  ago  pointed  out  by  Roki- 
tansky  and  other  pathologists.  This  theory  supposes  the  original  partial 
depression  and  relaxation  of  the  fundus.  How  this  is  often  produced 
by  mismanagement  of  the  third  stage  has  already  been  pointed  out ;  but, 
even  in  the  absence  of  such  causes,  it  may  result  from  strong  bearing- 
down  efforts  on  the  part  of  the  patient,  or,  as  Duncan  holds,  from  the 
absence  of  the  retentive  power  of  the  abdomen.  Indeed,  the  incompati- 
bility of  an  actively-contracted  state  of  the  fundus  with  the  partial 
depression  which  is  essential,  according  to  both  views,  for  the  produc- 
tion of  inversion,  is  the  strongest  argument  in  favor  of  Duncan's  theory. 

Taylor's  Theory. — A  totally  different  view  has  more  recently  been 
sustained  by  Dr.  Taylor  of  New  York,  who  maintains  that  "spontane- 
ous active  inversion  of  the  uterus  rests  upon  prolonged  natural  and  ener- 
getic action  of  the  body  and  fundus  :  the  cervix,  the  lower  part,  yielding 
first,  is  thus  rolled  out  or  everted  or  doubled  up,  as  there  is  no  obstruc- 
tion from  the  contractility  of  the  cervix,  which  is  at  rest  or  functionally 
paralyzed  ;  the  body  is  gradually,  sometimes  instantaneously,  forced  lower 
and  lower,  or  inverted."^  That  partial  inversion  may  commence  at  the 
cervix  was  pointed  out  by  Duncan  in  his  paper,  who  depicts  it  in  the 
accompanying  diagram  (Fig.  148),  and  states  it  to  be  of  not  unfrequent 
occurrence.  It  is  not  impossible  that  occasionally  such  a  state  of  things 
should  be  carried  on  to  complete  inversion.  But  there  are  serious  objec- 
tions to  the  acceptan(!e  of  Dr.  Taylor's  view  that  such  is  the  principal 
cause  of  inversion,  sinc(!  the  ])roc(!ss  al)ov('  (k'scribed  would  be  of  neces- 
sity a  slow  and  long-c^ontiniuid  one,  whei'cas  nothing  is  more  certain 
than  that  inversion  is  generally  sudden  and  acc-ompanied  by  acute  symp- 
1  New  York  Med.  Jaurn.,  187 a. 


446 


LABOR. 


Fig.  148. 


Illustrating  the  Commencement 

of  Inversion  at  the  Cervix. 

(After  Duncan.) 


toms  of  shock,  and  i.s  often  attended  by  severe  hemorrhage,  which  could 
not  occur  when  such  excessive  contraction  was  taking-  place. 

Treatment. — The  treatment  of  inversion  consists  in  restorino;  the  organ 
to  its  natural  condition  as  soon  as  possible.    Every  moment's  delay  only 

serves  to  render  restoration  more  difficult, 
as  the  inverted  portion  becomes  swollen  and 
strangulated  ;  whereas  if  the  attempt  at  repo- 
sition be  made  immediately  there  is  generally 
comparatively  little  difficulty  in  eft'ecting  it. 
Therefore  it  is  of  the  utmost  importance  that 
no  time  should  be  lost  and  that  we  should  not 
overlook  a  partial  or  incomplete  inversion. 
Hence  the  occurrence  of  any  unusual  shock, 
pain,  or  hemorrhage  after  delivery  without 
any  readily-ascertained  cause  should  always 
lead  to  a  careful  vaginal  examination.  A 
want  of  attention  to  this  rule  has  too  often 
resulted  in  the  existence  of  partial  inversion 
being  overlooked  until  its  reduction  was  found 
to  be  difficult  or  impossible. 

Mode  of  Attempting  Reduction. — In  at- 
tempting to  reduce  a  recent  inversion  the 
inverted  portion  of  the  uterus  should  be 
grasped  in  the  hollow  of  the  hand  and 
pushed  gently  and  firmly  upward  into  its  natural  position,  great  care 
being  taken  to  apply  the  pressure  in  the  proper  axis  of  the  pelvis, 
and  to  use  counter-pressure,  by  the  left  hand,  on  the  abdominal 
walls.  Barnes  lays  stress  on  the  importance  of  directing  the  pressure 
toward  one  side,  so  as  to  avoid  the  promontory  of  the  sacrum.  The 
common  plan  of  endeavoring  to  push  back  the  fundus  fir.st  has  been 
well  shown  by  McClintock'^  to  have  the  disadvantage  of  increasing 
the  bulk  of  the  mass  that  has  to  be  reduced  ;  and  he  advises  that  while 
the  fundus  is  lessened  in  size  by  compression  we  should  at  the  same 
time  endeavor  to  push  up  first  the  part  that  was  less  inverted — that  is 
to  say,  the  portion  nearest  the  os  uteri.  Should  this  be  found  impossi- 
ble, some  assistance  may  be  derived  from  the  manoeuvre,  recommended 
by  Merriman  and  others,  of  first  endeavoring  to  push  up  one  side  or 
wall  of  the  uterus,  and  then  the  other,  alternating  the  upward  pressure 
from  one  .side  to  the  other  as  we  advance.  It  often  happens,  as  the 
hand  is  thus  applied,  that  the  uterus  somewhat  suddenly  reinverts  itself, 
sometimes  with  an  audible  noise,  much  as  an  india-rubber  bottle  would 
do  under  similar  circumstances.  When  reposition  has  taken  place,  the 
hand  .should  be  kept  for  .some  time  in  the  uterine  cavity  to  excite  tonic 
contraction  ;  or  Barnes's  suggestion  of  injecting  a  weak  solution  of  per- 
chloride  of  iron  may  be  adopted,  so  as  to  constrict  the  uterine  walls  and 
prevent  a  recurrence  of  the  accident. 

It  is  hardly  necessary  to  point  out  how  much  these  manoeuvres  will 
be  facilitated  by  placing  the  patient  fully  under  the  influence  of  an 
ansesthetic. 


'  Diseases  of  Woynen,  p.  79. 


INVERSION  OF  THE    UTERUS.  447 

Management  of  the  Placenta. — There  has  been  much  difference  of 
opinion  as  to  the  management  of  the  placenta  in  cases  in  which  it  is 
still  attached  when  inversion  occurs.  Should  we  remove  it  before 
attempting  reposition,  or  should  we  first  endeavor  to  reinvert  the 
organ  and  subsequently  remove  the  placenta  ?  The  removal  of  the 
placenta  certainly  much  diminishes  the  bulk  of  the  inverted  j)ortion, 
and  therefore  renders  reposition  easier.  On  the  other  hand,  if  there 
be  much  hemorrhage,  as  is  so  frequently  the  case,  the  removal  of  the 
placenta  ijiay  materially  increase  the  loss  of  blood.  For  this  reason 
most  authorities  recommend  that  an  endeavor  should  be  made  at  reduc- 
tion before  peeling  off  the  after-birth.  But  if  any  delay  or  difficulty  be 
experienced  from  the  increased  bulk,  no  time  should  be  lost,  and  it  is  in 
every  way  better  to  remove  the  placenta  and  endeavor  to  reinvert  the 
organ  as  soon  as  possible. 

Management  of  Cases  Detected  some  time  after  Delivery. — Supposing 
we  met  with  a  case  in  which  the  existence  of  inversion  has  been  over- 
looked for  days,  or  even  for  a  week  or  two,  the  same  procedure  must  be 
adopted ;  but  the  difficulties  are  much  greater,  and  the  longer  the  delay 
the  greater  they  are  likely  to  be.  Even  now,  however,  a  well-conducted 
attempt  at  taxis  is  likely  to  succeed.  Should  it  fail,  we  must  endeavor 
to  overcome  the  difficulty  by  continuous  pressure  applied  by  means  of 
caoutchouc  bags  distended  with  water  and  left  in  the  vagina.  It  is 
rarely  that  this  will  fail  in  a  comparatively  recent  case,  and  such  only 
are  now  under  consideration.  It  is  likely  that  by  pressure  applied  in 
this  way  for  twenty-four  or  forty-eight  hours,  and  then  followed  by 
taxis,  any  case  detected  before  the  involution  of  the  uterus  is  com- 
pleted may  be  successfully  treated. 

[Spontaneous  Reposition  of  the  Inverted  Uterus. — After  all  attempts 
have  failed  to  replace  an  inverted  uterus,  already  too  much  contracted 
to  yield  to  the  pressure  employed.  Nature  sometimes  accomplishes  the 
work  herself,  as  proved  beyond  question  from  quite  a  number  of  well- 
established  cases,  several  of  which  belong  to  our  own  country.  A  few 
years  ago  I  saw  one  of  the  most  remarkable  on  record.  A  woman  of 
29,  mother  of  three  children,  miscarried  at  six  and  a  half  months  from 
lifting.  From  the  time  of  her  delivery  she  was  subject  to  weepings  of 
blood,  and  at  times  to  more  or  less  severe  hemorrhages,  one  of  the  last 
of  which  nearly  proved  fatal.  This  condition  of  disease  had  lasted 
three  years,  when  Dr.  Walter  F.  Atlee  was  called  in  to  relieve  her  in  her 
worst  hemorrhagic  attack,  and  found  her  uterus  inverted,  and  a  nodular 
gro^^i:h  upon  the  fundus  which  gave  out  an  offensive  odor.  Thinking 
the  disease  ])ossibly  malignant,  and  believing,  in  any  event,  that  to  save 
th(!  woman  he  would  l)c  obliged  to  remove  the  uterus,  he  called  a  con- 
sultation and  ]ire])arcd  for  the  operation  ;  but  when  the  patient  was 
etherized,  ])lac('d  in  the  knee-elbow  position,  and  Sinis's  speculum  intro- 
duced, behold,  there  was  nothing  to  be  seen  in  the  vagina  but  a  soft 
dilat(,'d  cervix,  the  uterus  having  been  replaced  by  atmospheric  pressure, 
aided  perhaps  by  traction  on  the  uterine  attachments  witln'n.  When 
explon^d,  tiie  uterus  was  found  to  be  very  soft  and  thin,  and  to  contain 
some  hard  nochilar  masses,  whicli  on  removal  pr()V(!d  to  l)e  j)orlions  of 
an  adherent  |)iaceuta.     The  liemon-hagi;  ceased  u|)on  the  rej)osition  and 


448  LABOR. 

cleaning  out  of  the  uterus,  and  the  patient  made  a  good  recovery.  8he 
has  been  again  pregnant. 

This  woman  was  ansemic  to  a  marked  degree,  and  her  abdominal  walls 
80  thin  that  a  finger  in  the  uterus  could  readily  be  felt  above  the  pubes. 
There  is  not  the  slightest  doubt  about  the  inversion,  which  was  proved 
to  exist  a  short  time  before  the  change  of  posture  by  Prof.  Agnew,  who 
made  a  finger  in  the  rectum  meet  another  above  the  pubes,  and  there  was 
no  fundus  between  them. 

Two^  cases  are  upon  record  where  reposition  was  the  result  of  falls, 
one  at  eight  months  and  the  other  after  as  many  years.  Drs.  Moehring, 
C.  D.  Meigs,  H.  L.  Hodge,  and  Warrington  of  this  city  failed  to  replace 
a  uterus,  and  the  woman  again  became  pregnant  in  about  six  years,  abort- 
ing with  a  three  months'  foetus  under  the  care  of  Dr.  Warrington.  Dr. 
Meigs  saw  a  second  case  with  Dr.  Levis,  in  which  there  was  violent 
flooding  followed  by  hemorrhages,  which  gradually  declined.  After  her 
return  from  a  journey  West  she  became  pregnant  and  bore  a  child.  Dr. 
John  L.  Atlee  of  Lancaster  failed  to  replace  the  uterus  of  a  woman,  but 
she  recovered  spontaneously  and  bore  a  child  a  year  afterward.^  Dr. 
Johnson  F.  Hatch  of  Kent,  Connecticut,  reported  a  case  in  a  letter  to 
Dr.  C.  D.  Meigs  in  which  inversion  occurred  spontaneously  fourteen  or 
fifteen  hours  after  labor.  After  being  under  the  care  of  several  physi- 
cians, she  had,  at  the  end  of  eighteen  months,  two  severe  hemorrhagic 
attacks,  after  which  she  improved,  and  finally,  at  the  end  of  two  years 
and  nine  months,  bore  a  child  of  9  pounds  and  6  ounces. 

In  all  cases  spontaneous  reposition  appears  to  result  from  a  softening 
and  thinning  of  the  uterine  walls  as  the  result  of  anaemia  brought  on  by 
hemorrhages.  This  was  particularly  noticed  by  Boivin  and  Duges  in 
autopsies  of  women  dying  of  rej)eated  hemorrhages. — Ed.] 

['  See  Dailliez,  Essai  sur  le  Renversement  de  la  Matrice,  Paris,  1805,  pp.  105-107.] 
P  Meigs's  Obstetrics,  1852,  Philada.,  p.  608.] 


PART  IV. 

OBSTETRIC    OPERATIONS. 


CHAPTER   I. 

INDUCTION  OF  PREMATURE  LABOR. 

History  of  the  Operation. — The  first  of  the  obstetric  operations  we 
have  to  consider  is  the  induction  of  premature  labor — an  operation  which, 
like  the  use  of  forcej3S,  was  first  suggested  and  practised  in  this  country, 
and  the  recognition  of  which,  as  a  legitimate  procedure,  we  also  chiefly  owe 
to  the  labor  of  our  fellow-countrymen,  in  spite  of  much  opposition  both  at 
home  and  abroad.  It  is  not  known  with  certainty  to  whom  we  owe  the 
original  suggestion,  but  we  are  told  by  Denman  that  in  the  year  1756  there 
was  a  consultation  of  the  most  eminent  physicians  at  that  time  in  Lon- 
don to  consider  the  advantages  which  might  be  expected  from  the  opera- 
tion. The  proposal  met  with  formal  approval,  and  was  shortly  after  car- 
ried into  practice  by  Dr.  Macaulay,  the  patient  being  the  wife  of  a  linen- 
draper  in  the  Strand.  From  that  time  it  has  flourished  in  Great  Britain, 
the  sphere  of  its  application  has  been  largely  increased,  and  it  has  been 
the  means  of  saving  many  mothers  and  children  who  would  otherwise, 
in  all  probability,  have  perished.  On  the  Continent  it  was  long  before 
the  operation  was  sanctioned  or  practised.  Although  recommended  by 
some  of  the  most  eminent  German  practitioners,  it  was  not  actually  per- 
formed until  the  year  1804.  In  France  the  opposition  was  long  con- 
tinued and  bitter.  Many  of  the  leading  teachers  strongly  denounced  it, 
and  the  Academy  of  Medicine  formally  discountenanced  it  so  late  as  the 
year  1827.  The  objections  were  chiefly  based  on  religious  grounds,  but 
partly,  no  doubt,  on  mistaken  notions  as  to  the  object  proposed  to  be 
gained.  Although  frequently  discussed,  the  operation  was  never  actually 
carried  into  practice  until  the  year  1831,  when  Stoltz  performed  it  with 
success.  Since  that  time  opposition  has  greatly  ceased,  and  it  is  now 
enii)loyed  and  liighly  recommended  by  the  most  distinguished  obstetri- 
cians of  the  Frencli  scliools. 

(Jhjecis  of  the  Operation. — In  inducing  premature  labor  we  propose  to 
avoid  or  lessen  the,  risk  to  which,  in  certain  cases,  the  mother  is  ex])osed 
bvjjdjyeiT  at  term,  or  toTsave  the  life  of  thej^hildj  which  might  other- 
wiscTTKr^jndangered.  HenccTlhc!  (TpTi-iition  may  be_indicated_  either  on 
account  ofjhe  mother  alone  or  ()f  the  cliild  alone,  or,  as  not  unfrecjuently 
li;i])])('ns,  ()f'  both  totretlier. 

iJefeetive  Proportion  between  the  Child  and  Pelvis  the  most  Frequent 


29 


449 


450  OBSTETRIC  OPERATIONS. 

Indication. — In  by  far  the  largest  number  of  cases  the  operation  is  per- 
formed on  account  of  defective  proportioiL  between  the  child  ancMihe 
niaternaljDassages,  due  to  some  abnormal  condition  on  the  part  of  the 
mother.  This  want  of  proportion  may  depend  on  the  presence  of  tumors, 
either  of  the  uterus  or  growing  from  the  pelvis.  But  most  frequently 
it  arises  from  deformity  of  the  pelvis  (p.  398),  and  it  is  needless  to  repeat 
what  has  been  said  on  that  point.  I  shall  therefore  only  briefly  refer 
to  a  few  more  uncommon  causes  which  occasionally  necessitate  its  per- 
formance. 

Habitually  Large  Size  of  the  Foetal  Head. — One  of  these  is  an  habitii- 
ally  large  or  ojvrij^fiimll^ossified  Jret^  Should  we  meet  with  a 

case  in  which  the  labors  are  always  extremely  difficult  and  the  head 
apparently  of  unusual  size,  although  there  is  no  apparent  want  of  space 
in  the  pelvis,  the  induction  of  labor  would  be  perfectly  justifiable,  and 
in  all  probability  would  accomplish  the  desired  object.  In  such  cases 
the  full  period  of  delivery  would  require  to  be  anticipated  by  a  very 
short  time.  A  week  or  a  fortnight  might  make  all  the  difference  between 
a  labor  of  extreme  severity  and  one  of  comparative  ease. 

Condition  of  the  Mother^ 8  Health  calling  for  the  Operation. — There  is 
a  large  class  of  cases  in  which  the  condition  of  the  motlier^  indicates  the 
operation.  Many  of  these  have  already  been  considered  when  treating 
of  the  diseases  of  pregnancy.  Amongst  them  may  be  mentioned  vomit- 
ing which  has  resisted_all_treatment,  and  which  has  produced  a  state  of 
exhaustion  threatening  to  prove  fatal ;  chorea,  albuminuria,  convulsions, 
or  mania ;  excessive  anasarca,  ascites,  or  dyspnoea  connected  with  disease 
of  the  heart,  lungs,  or  liver,  which  may  be,  in  a  great  measure,  caused 
by  the  pressure  of  the  enlarged  uterus ;  in  fact,  any  condition  or  disease 
a^cting  the  mother,  provided  only  we  are  convinced  that  the  termina- 
tion of  pregna,ncy  would  g;ivejhe_{iatient  relief  and  that  its  continuance 
woidd  invoh^e  serious  danger.  It  need  hardly  be  pointed  out  that  the 
induction  of  labor  for  any  such  causes  involves  grave  responsibility  and 
is  decidedly  open  to  abuse :  no  jDractitioner  would,  therefore,  be  justified 
in  resorting  to  it,  especially  if  the  child  have  not  reached  a  viable  age, 
without  the  most  anxious  consideration.  No  general  rules  can  be  laid 
down.  Each  case  must  be  treated  on  its  own  merits.  It  is  obvious  that 
the  nearer  the  patient  is  to  the  full  periocl,  the  greater  will  be  the  chance 
of  the  child  surviving,  and  the  less  hesitation  need  then  be  felt  in  con- 
sulting the  interest  of  the  mother. 

Conditions  Affecting  the  Safety  of  the  Child  alone. — In  another  class 
of  cases  the  operation  is  indicated  by  circumstances  affecting  tlisJife  of 
the  child  alone.  Of  these  the  most  common  are  those  in  which  the_child 
dies,  in  several  successive  pregnancies,  before  the  termination  of  utero- 
gestation.  This  is  generally  the  result  of  fatty,  calcareous,  or  syphilitic 
degeneration  of  the  placenta,  which  is  thus  rendered  inca])able  of  per- 
forming its_functions.  These  changes  in  the  placenta  sejdom  commence 
untila  comparatively_adyaiiced  period  of  pregnancy,  so  that  if  labor  be 
somewhat  hastened  we  may  hope  to  enable  the  patient  to  give  birth  to  a 
living  and  healthy  child.  The  experience  of  the  mother  will  indicate 
the  period  at  which  the  death  of  the  foetus  has  formerly  taken  place,  as 
she  would  then  have  appreciated  a  difference  in  her  sensations,  a  dim- 


INDUCTION  OF  PREMATURE  LABOR.  451 

inutjon  in  the  vigor  of  the  foetal  movements,  a  s.ense  of  weight  and  cold- 
ness^ and  similar  signs.  For  some  weeks  before  the  time  at  which  this 
change  has  been  experienced  we  should  carefully  auscultate  the  foetal 
heart  from  day  to  day,  and  in  most  cases  the  approach  of  danger  will 
be  indicated  sufficiently  soon,  by_tumultuous  and  irregular  pulsations 
or  a  failure  in  their  strength  and  frequency,  to  enable  us  to  interfere  with 
success.  On  the  detectioii  of  thege,  or  on  the  mother  feeling  that  the 
movements  of  the  childare  becoming  less  strong,  the  operation  sliould 
at  once  be  performed.  Simpson  also  induced'premature  labor  with  suc- 
cess in  a  patient  who  had  twice  given  birth  to  hydrocephalic  children. 
In  the  third  pregnancy,  which  he  terminated  before  the  natural  period, 
the  child  was  well-formed  and  healthy. 

Induction  of  Labor  when  the  Mother  is  Mortally  III. — Some  obstetri- 
cians have  proposed  to  induce  labor,  with  the  view  of  saving  the  child, 
whgn_thejnotlierjyas  suifering_fi;omjnoi'tal  disease.  This  indication  is, 
however,  so  extremely  doubtful,  from  a  moral  point  of  view,  that  it  can 
hardly  be  considered  as  ever  justifiable. 

Various  Methods  of  Inducing  Labor:  their  Mode  of  Action. — Th^ 
roeans  adopted  for  the  induction  of  labor  are  very  numerous.  Som-i 
of  them  act  through  the  maternal  circulation,  as  the  administration  of 
ergot  and  other  ^oxytocics ;  others,  by  their  power  of  exciting  reflex 
action,  oinby  interfering  with  the  integrity  of  the  ovum,  or  by  a  com- 
bination of  both,  as  the  vaginal  douche,  separation  of  the  membranes 
from  the  ut_er[ne  myalls,  puncture  of  the  ovum,  dilatation  of  the  os,  stiin- 
ulating_enemata,  or  irritation  of  the  breasts.  The  former  class  are  never 
employed_in  modern  obstetric  practice.  Of  the  latter,  some  offer  spe- 
cial advantages  in  particular  cases,  but  none  are  equally  adapted  for 
all  emergencies.  Often  a  combination  of  more  methods  than  one 
will  be  found  most  useful.  I  shall  mention  the  various  methods  in 
use,  and  discuss  briefly  the  relative  advantages  and  disadvantages  of 
each. 

Puncture  of  Membranes. — The  evacuation  of  the  liquor  amnii  by  the 
puncture  of  the  membranes  was  the  jirst  method  practised,  and  was  that 
recommended  by  Denman  and  all  the  earlier  writers.  It  is  the  most 
certain  which  can  be  employed,  as  it  never  fails,  sooner  or  later,  to  induce 
uterine  contractions.  There  are,  however,  several  disadvantages  con- 
nected with  it  which  are  sufficient  to  contraindicate  its  use  in  the  major- 
ity of  cases.  It  is  uncertain  as  regards  tlie  time_taken  in  producing  the 
desired  effect,  pains  sometimes  coming  on  within  a  few  hours,  but  occa- 
sionally not  until  several  days  have  elapsed.  The  contracting  walls  of 
the  uterus  pr^s  directly  on  the  body  of  the  child,  which,  being  frail 
and  immature,  is  less  able  to  bear  the  pressure  than  at  the  full  period 
of  pregnancy.  Hence  it  involves  great  risk  to  the  foetus.  Besides,  the 
^jcape  of  the  water  does  away  with  the  fltiidj\vedgc  so  useful  in  dilating 
tlie  OS,  and  shoidd  version  be  necessary  from  mal])rescntation — a  com- 
])lication  more  likely  to  occur  than  in  natural  labor — the  operation  would 
have  to  be  pyforrned  under  very  unfavorable  conditions.  These  objec- 
tions are  suiticient  to  justify  the  ordinary  opinion  that  tliis  procoilnrejihould 
notjKi  adopted  unless  other  jjieniis  have  iLeonti^k'd  and  j'ailcd.  Every 
now  and  then   cases  are  met  with  in  whidi   it   is  extrcjiuiiy  dilficidt  to 


452  OBSTETRIC  OPERATIONS. 

arouse  the  uterus  to  action,  and  under  such  circumstances,  in  Spite  of  its 
drawbacks,  this  method  will  be  found  to  be  very  valuable.  "VVheii  the 
ojjeration  has  to  be  performed_before  the^ child  isjviable — that  is,  before 
the  seventh  month — these  objections  do  no^hold,  and  then  it  is  the  sim- 
plest and  readiest  procedure  we  can  adopt.  Indeed,  in  producing  early 
ahortion  no  other  is  practicable.  The  (rperatjon  itself  is  most_simple, 
requiring  only  ajjuill,  stiletted  catheter,  or  other  suitable  instrument  to 
be  passed  upjto  the  os,  carefully  guarded  by  thejingers  of  the  left  hand 
previoiislyj^ntroduced,  and  to  be^  pressed  against  the  membranes  until 
perforation  is  accomplislied.  Meissner  of  Leipsic  has  proposed  as  a 
modification  of  this  plan  that  the  membranes  should  be  punctured 
obliquely  three  or  four  inches  above  the  os,  so  as  to  admit  of  a  gradual 
and  partial  escape  of  the  amniotic  fluid,  thus  lessening  the  risk  to  the 
child  from  pressure  by  the  uterus.  For  this  purpose  he  emjiloyed  a 
curved  silver  canula  containing  a  small  trocar,  which  can  be  projected 
after  introduction.  The  risk  of  injuring  the  uterus  by  such  an  instru- 
ment would  be  considerable,  and  we  have  other  and  better  means  at  our 
command  which  render  it  unnecessary.  When  we  require  to  produce 
early  abortion,  it  would  be  well  not  to  attempt  to  puncture  the  mem- 
branes with  a  sharp-pointed  instrument.  The  object  can  be  effected 
with  certainty  and  greater  safety  by  passing  an  ordinary  uterine  sound 
through  the  os  and  turning  it  round  once  or  twice. 

Administration  of  Oxytocics. — The  administration  of  ergot  of  rye, 
either  alone  or  combined  with  borax  and  cinnamon,  has  been  sometimes 
resorted  to.  This  practice  has  been  principally  advocated  by  Rams- 
botham,  who  was  in  the  habit  of  exhibiting  scruple  doses  of  the  pow- 
dered ergot  every  fourth  hour  until  delivery  took  place.  Sometimes  he 
found  that  as  many  as  thirty  or  forty  doses  were  required  to  effect  the 
object ;  occasionally,  labor  commenced  after  a  single  dose.  Finding 
that  the  infantile  mortality  was  very  great  when  this  method  was  fol- 
lowed, he  modified  it,  and  administered  two  or  three  doses  only,  and  if 
these  proved  insufficient  he  punctured  the  membranes.  There  can  be  no 
doubt  that  ergot  possesses  the  power  of  inducing  uterine  contractions. 
The  risk  to  the  child  is,  however,  quite  as  great  as  wdien  the  membranes 
are  punctured,  for  not  only  is  it  subject  to  injurious  pressure  from  the 
tumultuous  and  irregular  contractions  which  the  ergot  produces,  but  the 
drug  itself,  when  given  in  large  doses,  seems  to  exert  a  poisonous  influ- 
ence on  the  fostus.  For  these  reasons  ergot  may  pr.operly  be  excluded 
from  the  available  means  of  inducing  labor. 

Methods  Acting  Indirectly  on  the  Uterus. — Various  methods  have 
been  recommended  which  act  indirectly  on  the  uterus,  the  source  of  irri- 
tation being  at  a  distaiice.  Thus,  D'Outrepont  used  frequently-repeated 
ahdominaj/jHclionTirnd  tight  bandages.  Scanzoni,  remembering  the 
intimate  connection  between  the  mammse  and  uterus,  and  the  tendency 
which  irritation  of  the  former  has  to  induce  contraction  of  the  latter, 
recxmiuendedjthe  frequent  application  of  cupj^ing-glassesjo^ thc^l^reasts. 
Radford  and  others  have  employed  galvanism.  Stimulating  enemata 
have  been  employed.  AlHhege  methods  have  occasionally  proved  suc- 
cessftd,  and,  unlike  the  former  plans  we  have  mentioned,  they  are  iiot 
attended  by  any  special  rjsk  to  the  child.     They  are,  however,  much 


INDUCTION  OF  PREMATURE  LABOR. 


453 


Barnes's  Baa  i 
Dilating  the 
Cervix. 


too  uncertain  to  be  relied  on,  besides  being  irksome  both  to  the  patient 
and  practitioner. 

Artificial  Dilatation  of  the  Os  Uteri. — The  artificial  dilatation  of  the 
QSjiteiiL  in  imitation  of  its  natural  opening  in  labor,  was  first  practised 
by  Kliige.     He  was  in  the  habit  of  passing  within  the 
OS  a  tent  made  of  compressed  sponge  and  allowing  it  to  ^^'  ^^' 

dilate  by  imbibition  of  fluid.  If  labor  were  not  pro- 
voked within  twenty-four  hours,  he  removed  it,  and 
introduced  one  of  larger  dimensions,  changing  it  as  often 
as  was  necessary  until  his  object  was  accomplished.  Al- 
though this  operation  seldom  failed  to  induce  labor,  it 
had  the  disadvantage^  of  occupying  an  indefinite  time  and 
the  irritation  prothiceclwas  often  painful  and  annoying. 
Dr.  Keiller  of  Edinburgh  was  the  first  to  suggest  the 
use  of  caoutchouc  bags  distended  by  air  as  a  means  of 
dilating  the  os.  This  plan  has  been  perfected  by  Dr. 
Barnes  in  his  well-known  dilators,  which  are  of  great 
use  in  many  cases  in  which  artificial  dilatation  of  the 
cervix  is  necessary.  They  consist  of  a  series  of  india- 
rubber  bags  of  various  sizes,  with  a  tube  attached  (Fig. 
149),  through  which  water  can  be  injected  by  an  ordi- 
nary Higginson's  syringe.  They  have  a  small  pouch 
fixed  externally,  in  which  a  sound  can  be  placed,  so  as  to  facilitate  their 
introduction.  When  distended  with  water  the  bags  assume  somewhat 
of  a  fiddle  shape,  bulging  at  both  extremities,  which  ensures  their  being 
retained  within  the  os.  When  first  introduced  into  practice  as  a  means 
of  inducing  labor,  it  was  thought  that  this  method  gave  a  complete  con- 
trol over  the  process,  so  that  it  could  be  concluded  within  a  definite  time 
at  the  will  of  the  operator.  The  experience  of  those  who  have  used  it 
much  has  certainly  not  justified  this  anticipation.  It  is  true  that  occa- 
sionally contractio)is  supervene  within  a  few  hours  after  dilatation  has 
been  commenced,  but,  on  the  other  hand,  the  uterus  often  responds  very 
imperfectly  to  this  kind  of  stimulus,  and  the  bags  may  be  inserted  for 
many  consecutive  hours  without  the  desired  result  supervening,  the 
puncture  of  the  membranes  being  eventually  necessary  in  order  to  hasten 
the  process.  Indeed,  iny  own  experience  would  lead  me  to  the  conclu- 
s|onJjiat  as  a  means  of  evoking  uterine  contraction  cervical  dilatation  is 
very  unsatisfactory.  Dr.  Barnes  himself  has  evidently  seen  reason  to 
modify  his  original  views,  for  Mdiile  he  at  first  talked  of  the  bags  as 
enaljling  us  to  induce  labor  with  certainty  at  a  given  time,  he  has  since 
recomme-nded  that  uterine  action  should  be  first  provoked  by  other 
means,  tlie  dilators  being  subsequently  used  to  accelerate  the  labor  thus 
brought  on.  The  bags,  thus  employed,  find,  as  I  believe,  their  most 
useful  and  a  very  valuable  application  ;  but  when  used  in  this  way  they 
canufjt  be  considered  a  means  of  originating  uterine  action.  A  subsid- 
iary objection  to  tli(i  bags  is  tlu;  risk  of  dis])lacing  the  pr(;sentin)<»;  paii;. 
I  have,  for  cxainplc,  introduccMl  th(;m  when  tlie  head  was  presenting, 
aiifl  on  their  removal  found  the  shoulder  lying  over  tlie  os.  It  is  not 
difficult  to  understand  how  the  continuous  pressure  of  a  distended  bag 
in  tli(!  internal  os  might  easily  push  away  the  head,  which  is  so  readily 


454  OBSTETRIC  OPERATIONS. 

movable  so  long  as  the  membranes  are  unruptured.  Still,  if  labor  be  in 
progress  and  the  os  insufficiently  dilated,  the  possibility  of  this  occur- 
rence  is  not  a  suilieient  reason  for  not  availing  ourselves  of'the  undoubt- 
^I^^valuable  assistance  which  the  dilators  are  capable  oF^mug. 

Separation  of  the  Membranes. — Some  processes  foF  inducing  labor  act 
directly  on  the  ovum  by  separating  the  membranes,  to  a  greater  or  less 
extent,  from  the  uterine  walls.  The  first  procedure  of  the  kind  was 
recommended  by  Dr.  Hamilton  of  Edinburgh,  and  consisted  in  the 
gradual  separation  of  the  membranes  for  one  or  two  inches  all  around 
the  lower  segment  of  the  uterus.  To  reach  them  the  finger  had  to  be 
gently  insinuated  into  the  interior  of  the  os,  which  was  gradually  dilated 
to  a  sufficient  extent  by  a  series  of  successive  operations  repeated  at 
intervals  of  three  or  four  hours.  When  this  had  been  accomplished,  the 
fore  finger  was  inserted  and  swept  round  between  the  membranes  and  the 
uterus ;  but  it  was  frequently  found  necessary  to  introduce  the  greater 
part  of  the  hand  to  effect  the  object,  and  sometimes  even  this  was  not 
sufficient,  and  a  female  catheter  or  other  instrument  had  to  be  used  for 
the  purpose.  The  method  was  geiierally  successful  in  bringing  on  labor, 
but  it  now  and  then  failed,  even  in  Dr.  Hamilton's  hands.  It  is  cer- 
tainly based  on  correct  principles,  but  it  is  tedious  and  painful  both  to 
the  practitioner  and  the  patient,  and  very  uncertain  in  its  time  of  action. 
For  these  reasons  it  has  never  been  much  practised. 

Vaginal  and  Uterine  Douches. — In  the  year  1836,  Kiwisch  suggested 
a  plan  which  from  its  simplicity  has  met  with  much  approval.  It  con- 
sists in_j3rqiecting_atjntervals  a  stream  of  warm  or  cold  water  against 
the  osliteriT^Its  action  is  doubtless  complexT  Kiwisch  himself  believed 
that  relaxation  of  the  soft  parts  through  the  imbibition  of  water  was  the 
determining  cause  of  labor.  Simpson  found  that  the  method  failed  unless 
the  Avater  mechanically  separated  the  membranes  from  the  uterine  Avails. 
Besides  this  effect,  it  probably  directly  induces  reflex  action  by  distend- 
ing the  vagina  and  dilating  the  os.  In  using  it,  it  has  been  customary 
to  administer  a  douche  twice^dajlx,^  and  moreJrequently_ifj^ 
be  desired.  The  number  required  varies  in  different  cases.  The  largest 
number  Kiwisch  found  it  necessary  to  use  was  17,  the  smallest  5.  The 
average  time  that  elapses  before  labor  sets  in  is  four  days.  Hence  the 
method  is  obviously  useless  when  rapid^jdelivery  is  required. 

Dr.  Cohen  of  Hamburg  introduced  an  important  modification  of  the 
process  which  has  been  considerably  practised.  It  consists  in  ijasgJHg:  a 
silver  or  gum-elastic  catheter_§ome_iiK^s  within  the  os,  between  the 
membranes  and  the  uterinewalls,  and  injecting  the  fluid  through  it 
dn^jy^to^tHe^ca^oty^f^^^  He  used  creasote  or  tar-water, 

and  irjected_wrtlipuj^()p^ 

of  distension.  Others  have  found  the  plan  equally  efficacious  when  they 
only  employed  a  small  quantity  of  plain  water,  such  as  7  or  8  ounces. 
Professor  Lazarewitch  of  Charkoff  is  a  strong  advocate  of  this  method. 
He  believes  that  uterine  action  is  evoked  much  more  rapidly  and  cer- 
tainly if  the  water  be  injected  near  the  fundus,  and  he  has  contrived  an 
instrument  for  the  purpose  with  a  long  metallic  nozzle. 

Dangers  of  these  Pkms, — So  many  fatal  cases  have  followed  these 
methods  that  it  cannot  be  doubted  that,  in  spite  of  their  certainty  and 


INDUCTION  OF  PREMATURE  LABOR.  455 

simplicity,  there  is  an  element  of  risk  in  them  that  should  not  be  over- 
looked. Many  of  these  are  recorded  in  Barnes's  work,  and  he  comes  to 
the  conclusion,  which  the  facts  unquestionably  justify,  that  "  the  douche, 
whether  vao^inal  or  intra-uterine,  ought  to  be  absolutely  condemned  as 
a~means  of  inducing  labor."  The  precise  reason  of  the  danger  is  not 
very  obvious.  Sudden  stretching  of  the  uterine  walls,  producing  sliock, 
has  been  supposed  to  have  caused  it ;  but  in  many  of  the  fatal  cases  the 
symptoms  have  been  rather  those  attending  the  passage  of  air  into  the 
veinSj  and  it  is  easy  to  understand  how  air  may  have  been  introduced  in 
this  way  into  the  large  uterine  sinuses. 

Injection  of  Carbonic  Acid  Gas. — Simpson  and  Scanzoni  have  both 
tried  witlj_success^the  injection  of  carbonic  acid  gas  into  the  vagijia. 
Fatal  results  have,  however,  followed  its  employment,  and  .Simpson  has 
expjressed  an  opinion  that  the  experiment  should  not  be  repeated. 

Simpson's  Method  of  Oi^erating. — Simpson  originally  induced  labor 
by  passing  the  uterine  sound  within  the  os  and  up  to^varx^tEe^^ndl^s, 
and  when  it  has  been  inserted  to  a  sufficient  extent^'moving  it  slightly 
from_sideJo_side!  He  was  led  to  adopt  this  procedure  in  the  beliefthat 
we  might  thus  closely  imitate  the  separation  of  the  decidua  which  occurs 
previous  to  labor  at  term.  Uterine  contractions  were  induced  with  cer- 
tainty and  ease,  but  it  was  found  impossible  to  foretell  what  time  might 
elapse  between -the  commencement  of  labor  and  the  operation,  which  had 
frequently  t(7  be  peribrmed  more  than  once.  He  subsequently  jiiodified 
this  procedure  byjiitroducingj^exible  male  catheter  without  a  stilette, 
which  he  allowed  to  remain  in  the  uterus  until  contractions  were  excited. 
THi^^an  is  much  used  in  Germany,  and  is  now  that  which  is  also  most 
frequently  adopted  in  this  country.  It  is  simple  and  very  effjcacioiis, 
pains  coming  on  almost  invariably  within  twenty-fonr  hours  after  the 
catheter  or  bougie  is  introduced.  A  theoretical  objection  is  the  possibil- 
ity7)f^the  catheter  separating  a  portion  of  the  placenta  and  giving  rise 
to  hemorrhage ;  but  in  practice  this  has  not  been  found  to  occur,  and 
the  risk  might  generally  be  avoided  by  introducing  the  catheter  at  a  dis- 
tance from  the  placenta,  the  probable  situation  of  which  has  been  ascer- 
tained by  auscultation.  The  more  deeply  the  cathetexjs  introduced,  the 
more  certain  and  rajjid  is  its  effect,  and  not  less  than  seven  inches  should 
be  pushed  ivpjwithiii_the  os.  It  is  not  always  easy  to  insert  it  so  far, 
especially  if  a  flexible  catheter  be  used,  which  is  apt  to  be  too  pliable  to 
pass  upward  with  ease.  A  solid  bougie — male  urethral  bougie — should 
therefore  be  employed ;  and  I  have  lolind  its  introduction  greatly  facil- 
itated by  anaesthetizing  the  patient  and  passing  the  greater  part  of  the 
hand  into  the  vagina.  In  this  way  it  can  be  pushed  in  very  gently  and 
witliout  any  risk  of  injury  to  the  uterus.  There  is  some  chance  of  riip- 
tui^ing  the  membranes  while  pushing  it  upward.  This  accident,  indeed, 
cannot  always  be  avoided,  even  when  the  greatest  care  is  taken ;  but 
when  it  occurs  the  puncture  will  be  at  a  distance  from  the  oSj  so  that  a 
small  portion  only  of  the  liquor  amnii  will  escape  :  and  this  can  scarcely 
be  CdDijJdercd  a  serious  o])jection.  It  is  always  an  advantage  to  allow 
the  pains  to  come  on  gradually  and  in  imitation  of  natural  laV)or. 
Tliorefore,  ]fj  after  the  bougie  has  been  inserted  for  a  sufficient  time, 
utcaine_contractions  come  on  sufficiently  strongly,  we  may  leave  the  case 


456  OBSTETRIC  OPERATIONS. 

to  be  terminated  naturally ;  or  if  tjiey  be  comparatively  feeble,  Ave  may 
rggQlLJ-O-accsl^rative  procedures — -viz.  dilatation  of _the^^ryix  by  the 
fluid  bags,  and  subsequently  the  puncture  of  the  membranes.  In  this 
way  we  have  the  labor  completely  under  control  ;  and  I  believe  this 
method  will  commend  itself  to  those  who  have  experience  of  it  as  the 
simplest  and  most  certain  mode  of  inducing  labor  yet  known,  and  the 
one  most  closely  imitating  the  natural  process.  Of"  late  I  have  been  in 
the  habit  of  combining  dilatation  of  the  cervix  with  this  method,  by 
means  of  a  well-carbolized  sponge  tent  passed  into  the  cervix  afi:er_the 
bougie  is  in  position.    In_tenj)rjtwe]yelno^  the  tent  and  bougie 

are  removed,  l:lie_ceryixjs^ound^jwel  dilated  and  ready  for  the  joassage 
of  tlie  child. 

The  Child  is  Immature  and  Dijficidt  to  Rear. — It  should  not  be  for- 
gotten that  the  child  is  immature,  and  that  unusual  care  is  likely  to  be 
required  to  rear  it  successfully.  We  should,  therefore,  be  careful  to 
have  at  hand  all  the  usual  means  of  resuscitation ;  and,  as  the  mother 
may  not  be  able  to  nurse  at  once,  it  would  be  a  good  precaution  to  have 
a  healthy  wet-nurse  in  readiness. [^] 

[Through  the  kindness  of  Dr.  Cesare  Belluzzi  of  Bologna  I  have 
received  his  two  reports,  containing  the  records  of  112  cases  in  which 
he  brought  on  labor  prematurely,  with  a  saving  of  104  mothers  and  the 
delivery  of  as  many  living  children.  42  patients  w^ere  treated  in  private 
practice  and  70  in  the  Maternity  of  Bologna.  In  9  patients  labor  was 
induced  because  of  disease  in  the  mother ;  in  1  it  was  brought  on  be- 
cause the  foetus  had  usually  died  in  the  ninth  month  of  former  preg- 
nancies; and  in  102  the  pelvis  was  contracted.  Of  these  102,  6  died — 3 
out  of  38  in  private  practice,  and  3  out  of  64  in  the  hospital.  Of  the 
9  women  operated  upon  because  of  serious  disease,  7  recovered.  35  out 
of  42  infants  were  delivered  alive  in  private  practice,  and  62  out  of  70 
in  the  Maternity. 

Dr.  Ludwig  Winckel  of  Miilheim,  Germany,  has  also  sent  me  his 
record  of  25  deliveries  in  women  who  were  all  the  subjects  of  contrac- 
tion of  the  pelvis.  These  patients  all  recovered:  14  children  were  still- 
born and  13  were  living;  of  the  latter,  only  7  were  alive  at  the  end  of 
two  weeks.  The  prolonged  vitality  of  the  foetus  is  largely  de]3endent 
upon  the  period  in  gestadon  which_is_chosen_fojM^  :  the 

later  the  deTivery,  the  l7ettiiLJs_the  prospect  of  ultmiate_gafetv.  But 
a  small  proportion  of  the  _children  reach  maturity.  Of  32  delivered 
alive  in  hospital  in  a  period  of  less  than  ten  years  under  Dr.  Belluzzi, 
27  were  dead  before  the  expiration  of  the  first  year,  and  29  in  all 
within  two  years  of  birth, — Ed.] 

\}  In  some  of  the  European  maternities  they  now  have  in  use  a  little  heated  cham- 
ber in  which  the  infant  is  put  to  sleep ;  it  is  kept  warm,  on  the  principle  of  an  egg- 
hatching  machine,  by  a  lamp  and  water-chamber. — Ed.] 


TURNING.  457 


CHAPTER  II. 
TURNING. 

History  of  the  Operation. — Turning — by  which  we  mean  the  alteration 
of  the  position  of  the  foetus,  and  the  substitution  of  some  other  portion 
of  the  body  for  that  originally  presenting — is  one  of  the  most  important 
of  obstetric  operations  and  merits  careful  study.  It  is  also  one  of  the 
most  ancient,  and  was  evidently  known  to  the  Greek  and  Roman  phy- 
sicians. Up  to  the  fifteenth  century,  cephalic  version — that  in  which 
the  head  of  the  foetus  is  brought  over  the  os  uteri — was  almost  exclus- 
ively practised,  when  Par6  and  his  pupil  Guillemeau  taught  the  pro- 
priety of  bringing  the  feet  down  first.  It  was  by  the  latter  physician 
especially  that  the  steps  of  the  operation  were  clearly  defined ;  and  the 
French  have  undoubtedly  the  merit  both  of  perfecting  its  performance 
and  of  establishing  the  indications  which  should  lead  to  its  use.  Indeed, 
it  was  then  much  more  frequently  performed  than  in  later  times,  since 
no  other  means  of  effecting  artificial  delivery  were  known  which  did  not 
involve  the  death  of  the  child ;  and  practitioners  doubtless  acquired 
great  skill  in  its  performance,  and  were  inclined  to  overrate  its  import- 
ance and  extend  its  use  to  unsuitable  cases.  An  opposite  error  Avas 
fallen  into  after  the  invention  of  the  forceps,  which  for  a  time  led  to 
the  abandonment  of  turning  in  certain  conditions  for  which  it  was  well 
adapted  and  in  which  it  has  only  of  late  years  been  again  practised. 

Cephalic  Version. — Cephalic  version  has,  since  Par§  wrote,  been 
recommended  and  practised  from  time  to  time,  but  the  difficulty  of 
performing  it  satisfactorily  was  so  great  that  it  never  became  an  estab- 
lished operation.  Dr.  Braxton  Hicks  has  perfected  a  method  by  which 
it  can  be  accomplished  with  greater  ease  and  certainty,  and  which  ren- 
ders it  a  legitimate  and  satisfactory  resort  in  suitable  cases.  To  him  we 
are  also  indebted  for  introducing  a  method  of  turning  without  passing 
the  entire  hand  into  the  cavity  of  the  uterus,  which,  under  favorable 
circumstances,  is  not  only  easy  of  performance,  but  deprives  the  opera- 
tion of  one  of  its  greatest  dangers. 

Turning  hy  External  and  Internal  Manipulation. — The  possibility  of 
effecting  version  by  external  manipulation  has  long  been  known,  and 
was  distinctly  referred  to  and  recommended  by  Dr.  John  Pechey^  so  far 
back  as  the  year  1698.  Since  that  time  it  has  been  strongly  recom- 
mended Ijy  Wigand  and  his  fc^llowers ;  and  various  authors  in  this 
country,  notably  Sir  James  Simjison,  have  referred  to  the  advantage  to 
Ix;  deriv(!d  from  external  manipulation  assisting  the  hand  in  the  interior 
of  the  uterus..  In  1 854,  Dr.  AVright  of  Cincinnati  advocated  the  appli- 
cation of  the  bi-manual  method  in  arm  and  shoulder  presentations, 
chiefly  with  the  view  of  effecting  cephalic  version.  To  Dr.  Hicks, 
however,  incontestably  belongs  the  merit  of  having  been  the  first  dis- 

^  The  Complete  3Iidwife'ii  rraelice,  p.  142. 


458  OBSTETRIC  OPERATIONS. 

tinctly  to  show  the  possibility  of  effecting  complete  version  in  all  cases 
in  which  the  operation  is  indicated  by  combined  external  and  internal 
manipulation,  of  laying  down  definite  rules  for  its  practice,  and  for  thus 
popularizing  one  of  the  greatest  improvements  in  modern  midwifery. 

Object  and  Nature  of  the  Operation. — The  operation  is  entirely  cle- 
pendent  for  success  on  the  fact  that  the^chJldLjiLlitero  is  freely  lagya- 
ble,  and  tjiat  its  position  may  be  artificially  altered  with  facility.  As 
long  as  tlie^jjgmbraiies^are^nru  and  the  foetus  is  flojting_hi  the 

suiTOimdingJluidji^^  it  is  liable  to  constant  changes  in  jjosition,  as 
may  be  readily  demonstrated  in  the  latter  months  of  pregnancy ;  and 
the  operation  under  these  circumstances  may  be  performed  with  the 
greatest  facility.  Shortly  after  the  liquor  amnii  has  escaped  there  is 
still,  as  a  rule,  no  great  difficulty  in  ef|ectjng_version,  but,  as  the  body 
is  no  longer  floating  in  the  surrounding  liquid,  its  rotation  must  neces- 
sarily be  attended  with  some  increased  risk  of  injury  to  the  uterus.  If 
the  liquor  amnii  have  been  long  evacuated' and  the  muscular  structure 
of  the  uterus  be  strongly  contracted,  the  fcetus  may  be  so  firmly  fixed 
that  any  attempt  to  move  it  is  surrounded  with  the  greatest  difficul- 
ties, and  may  even  fail  entirely  or  be  attended  with  such  risks  to  the 
maternal  structures  as  to  be  quite  unjustifiable. 

Cases  Suitable  for  the  Operation. — Version  may  be  required  either 
on  account  of  the  mother  or  child  alone,  or  it  may  be  indicated  by  some 
condition  imperilling  both  and  rendering  immediate  delivery  necessary. 
The  chiefcases  in  which  it  is  resorted  to  are  those  of  transverse  presen- 
tation,  where^it  is  absolutely  essential ;  accidental  or  unavoidable  hem- 
orrhage ;  certain  cases  of  contracted  pelvis ;  and  some  complications, 
especially^jjTolapse  of  the  funis.  The  special  indications  for  the  opera- 
tion have  been  separately  discussed  under  these  subjects. 

Statistics  and  Dangers  of  the  Operation. — The  ordinary  statistical 
tables  cannot  be  depended  on  as  giving  any  reliable  results  as  to  the 
risks  of  the  operation.  Taking  all  cases  together,  Dr.  Churchill  esti- 
mates the  niaternal^  rnortality_as  J_jn_16,  ancl  the  infantile^as  JL  in  3. 
Like  all  similar  statistics,  they  are  open  to  the  objection  of  not  distin- 
guishing between  the  results  of  the  operation  itself  and  of  the  cause 
M'hich  necessitated  interference.  Still,  they  are  sufficient  to  show  that 
the  operation  is  not  free  from  grave  hazards,  and  that  it  must  not  be 
undertaken  without  due  reflection.  The  principal  dangers  will  be  dis- 
cussed as  we  proceed.  It  may  suffice  to  mention  here  that  those  to  the 
mother  must  vary  with  the  period  at  which  the  operation  is  undertaken. 
If  version  be  performed  early,  before  the  rupture  of  the  membranes,  or 
in  favorable  cases  without  the  introduction  of  the  hand  into  the  interior 
of  the  uterus,  the  risk  must  of  course  be  infinitely  less  than  in  those 
more  formidable  cases  in  which  the  waters  have  long  escaped  and  the 
hand  and  arm  have  to  be  passed  into  an  irritable  and  contracted  uterus. 
But  even  in  the  most  unfavorable  cases  accidents  may  be  avoided  if  the 
operator  bear  constantly  in  mind  that  the  principal  danger  consists  in 
laceration  of  the  uterus  or  vagina  from  undue  force  being  employed  or 
from  the  hand  and  arm  not  being  introduced  in  the  axis  of  the  passages. 
There  is  no  operation  in  which  gentleness,  absence  of  all  hurry,  and 
-  complete  presence  of  mind  are  so  essential.     A  certain  number  of  cases 


TURNING.  459 

end  fatally  from  shock  or  exhaustion  or  from  subsequent  complications. 
As  regards  the  child,  the  mortality  is  little,  if  at  all,  greater  than  in 
original  breech  and  footling  presentations.  Nor  is  there  any  good  rea- 
son why  it  should  be  so,  seeing  that  cases  of  turning,  after  the  feet  are 
brought  through  the  os,  are  virtually  reduced  to  those  of  feet  presenta- 
tion, and  that  the  mere  version,  if  effected  sufficiently  soon,  is  not  likely 
to  add  materially  to  the  risk  to  which  the  child  is  exposed. 

Version  by  External  Manipulation. — The  possibility  of  effecting  ver- 
sion by  external  manipulation  has  been  recognized  by  various  authors, 
and  was  made  the  subject  of  an  excellent  thesis  by  Wigand,  who  clearly 
described  the  manner  of  performing  the  operation.  In  spite  of  the  man- 
ifest advantages  of  the  procedure,  and  the  extreme  facility  with  which  it 
can  be  accomplished  in  suitable  cases,  it  has  by  no  means  become  the 
established  custom  to  trust  to  it,  and  probably  most  practitioners  have 
never  attempted  it,  even  under  the  most  favorable  conditions.  The  pos- 
sibility of  the  operation  is  based  on  the  extreme  mobility  of  the  foetus 
before  the  meinbranes  are  ruptured.  After  the  w^aters  have  escaped  the 
uterine  walls  embrace  the  foetus  more  or  less  closely,  and  version  can  no 
longer  be  readily  performed  in  this  manner. 

Cases  Suitable  for  the  Operation. — It  may,  therefore,  be  laid  down  as 
a  rule  that  it  should  only  be  attem])ted  when  the  abnormal  position  of 
the  foetus  is  detected  before  labor  has  commenced,  or  in  the  early  stage 
of  labor  when  the  membranes  are  unruptured.  It  is  also  unsuitable  for 
any  but  transverse  presentations,  for  it  is  not  meant  to  effect  complete 
evolutionjof  the  foetus,  but  only  to  substitute  the  head  for  the  upper 
extremity.  It  is  useless  whenever  rapid  delivery  is  indicated,  for  after 
the  head  is  broug-ht  over  the  brim  the  conclusion  of  the  case  must  be  left 
to  the  natural  powers. 

The  manner  of  detecting  the  presentation  by  palpation  has  been  already 
described  (p.  121),  and  the  success  of  the  operation  depends  on  our  being 
able  to  ascertain  the  positions  of  the  head  and  breech  through  the  ute- 
rine walls.  Should  labor  have  commenced  anol  the  os  be  dilated,  the 
transverse  presentation  may  be  also  made  out  by  vaginal  examination. 
Should  the  abnormal  presentation  be  detected  before  labor  has  actually 
begun,  it  is  in  most  cases  easy  enough  to  alter  it  and  to  bring  the  foetus 
into  the  longitudinal  axis  of  the  uterine  cavity.  Pinard  ^  recommends 
that  after  this  has  been  done  the  foetus  should  be  maintained  in  position 
by  a  well-fitting  elastic  abdominal  belt.  It  is  seldom,  however,  discov- 
ered until  labor  has  commenced,  and,  even  if  it  be  altered,  the  child  is 
extremely  apt  to  resume  in  a  short  time  the  faulty  position  in  which  it 
was  formerly  lying.  Still,  there  can  be  no  harm  in  making  the  attempt, 
since  the  operation  itself  is  in  no  way  painful,  and  is  absolutely  without 
risk  either  to  the  mother  or  child.  When  the  transverse  presentation  is 
detected  early  in  labor,  I  believe  it  is  good  practice  to  endeavor  to  rem- 
edy it  by  external  manipulation,  and  if  it  fail  we  may  at  once  proceed 
to  other  aufl  more  certain  methods  of  operating.  The  procedure  itself 
is  abundantly  sinijile.  The  patient  is  placed  on  her  back,  and  the  posi- 
tion of  the  foetus  ascertained  by  palpation  as  accurately  as  possible,  in 
the  manner  already  described.     The  palms  of  the  hands  being  then 

'  IM  la  Version  par  Manoeuvres  ezternes,  Paris,  1878. 


460  OBSTETRIC  OPERATIONS. 

placed  over  the  opposite  poles  of  the  foetus,  by  a  series  of  gentle  gliding 
movements  the  head  is  jjuBhKKLtowanHhejjglv  brim,  while  the  breech 
is  moved~iirthe  op])osite  direction.  The  facility  with  which  the  foetus 
may^ometimesHbe  moved'ln^ this  way  can  hardly  be  appreciated  by 
those  who  have  never  attempted  the  operation.  As  soon  as  the  change 
is  effected  the  long  diameters  of  the  foetus  and  the  uterus  will  corre- 
spond, and  vaginal  examination  will  show  that  the  shoulder  is  no  longer 
presenting  and  that  the  head  is  over  the  pelvic  brim.  If  the  os  be  suf- 
ficientlxjliM^^  and  labor  in  progress,  the  membranes  should  now  be 
punctured,  and  the  position  of  the  foetus  maintained  for  a  short  timejjy 
external  pressure  mrtil  we  are  certain  that  the  cgijhalicjjregentation  is 
peraiaiiently^^stablM^  If  labor  be  not  in  progress,  an  attempt  may 

at  least  be  made  to  effect  the  same  object  by  pads  and  a  binder,  one  pad 
being  placed  on  the  side  of  the  uterus  in  the  situation  of  the  breech,  and 
another  on  the  opposite  side  in  the  situation  of  the  head. 

Cephalic  Version. — On  account  of  the  difficulty  of  performing  cephalic 
version  in  the  manner  usually  recommended,  it  has  practically  scarcely 
been  attempted,  and  with  the  exception  of  some  more  recent  authors  it 
is  generally  condemned  by  wa^iters  on  systematic  midwifery.  Still,  the 
operation  offers  unquestionable  advantages  in  those  transverse  presenta- 
tions in  which  rapid  delivery  is  not  necessary,  and  in  which  the  only 
object  of  interference  is  the  rectification  of  malposition  ;  for  if  successful 
the  child  is  spared  the  risk  of  being  drawn  footling  through  the  pelvis. 
The  objections  to  cephalic  version  are  based  entirely  on  the  difficulty  of 
performance ;  and,  undoubtedly,  to  introduce  the  hand  within  the  ute- 
rus, search  for,  seize,  and  afterward  place  the  slippery  head  in  the  brim 
of  the  pelvis,  could  not  be  an  easy  process  even  under  the  most  favor- 
able circumstances,  and  must  always  be  attended  w^ith  considerable  risk 
to  the  mother.  Velpeau,  who  strongly  advocated  the  operation,  was  of 
opinion  that  it  might  be  more  easily  accomplished  by  pushing  up  the 
presenting  part  than  by  seizing  and  bringing  down  the  head.  Wigand 
more  distinctly  pointed  out  that  the  head  could  be  brought  to  a  proper 
position  by  external  manipulation,  aided  by  the  fingers  of  one  hand 
within  the  vagina.  Braxton  Hicks  has  laid  down  clear  rules  for  its 
performance  which  render  cephalic  version  easy  to  accomplish  under 
favorable  conditions,  and  will  doubtless  cause  it  to  become  a  recognized 
mode  of  treating  malpositions.  The  number  of  cases,  however,  in  which 
it  can  be  performed,  must  always  be  limited,  since,  as  in  turning  by  ex- 
ternaljnanipulation  alone,  it  is  necessary  that  the  liquoramnii  should 
be  still  retained,  or  at  least  have  only  recejitly_escape.d ;  that  the  pres- 
entatuHTbelr  movable^abOTtjhejielyii^^  ;  and  that  there  be  no 
njicessityJoLjapid  delivery.  Dr.  Hicks  does  not  believe  protrusion  of 
the  arm  to  be  a  contraindication,  and  advises  that  it  should  be  carefully 
replaced  within  the  uterus.  When,  however,  protrusion  of  the  arm  has 
occurred,  the  thorax  is  so  constantly  pushed  down  into  the  pelvis  that 
replacement  can  neither  be  safe  nor  practicable,  except  under  unusually 
fiworable  conditions,  and  podalic  version  Avill  be  necessary. 

Method  of  Performance. — It  is  impossible  to  describe  the  method  of 
performing  cephalic^yersion^  more  concisely  and  clearly  than  in  Dr. 
Hicks'  own  words.    "Introduce,''  he  says,  " the  left  hand  into  the  vagina, 


TUBNING.  461 

as  in  poclalic  version ;  place  the  right  hand  on  the  outside  of  the  abdo- 
men, in  order  to  make  out  the  position  of  the  foetus  and  the  direction 
of  its  head  and  feet.  Should  the  shoulder,  for  instance,  present,  then 
push  it  with  one  or  two  fingers  in  the  direction  of  the  feet.  At  the  same 
time  pressure  with  the  other  hand  should  be  exerted  on  the  cephalic  end 
of  the  child.  This  will  bring  the  head  down  to  the  os ;  then  let  the 
head  be  received  on  the  tips  of  the  inside  fingers.  The  head  will  play- 
like  a  ball  between  the  two  hands ;  it  will  be  under  their  command,  and 
can  be  placed  in  almost  any  part  at  will.  Let  the  head  then  be  placed 
over  the  os,  taking  care  to  rectify  any  tendency  to  face  presentation.  It 
is  as  well,  if  the  breech  will  not  rise  to  the  fundus  readily  after  the  head 
is  fairly  in  the  os,  to  withdraw  the  hand  from  the  vagina,  and  with  it 
press  up  the  breech  from  the  exterior.  The  hand  which  is  retaining 
gently  the  head  from  the  outside  should  continue  there  for  some  little 
time  till  the  pains  have  ensured  the  retention  of  the  child  in  its  new 
position  and  the  adaptation  of  the  uterine  walls  to  its  new  form.  Should 
the  membranes  be  perfect,  it  is  advisable  to  rupture  them  as  soon  as  the 
head  is  at  the  os  uteri ;  during  their  flow  and  after,  the  head  will  move 
easily  into  its  proper  position." 

The  procedure  thus  described  is  so  simple,  and  would  occupy  so  short 
a  time,  that  there  can  be  no  objection  to  trying  it.  Shoukl  we  fail  in 
our  endeavors,  we  shall  not  be  in  a  worse  position  for  eifecting  delivery 
by  podalic  version,  which  can  be  proceeded  with  without  withdrawing 
the  hand  from  the  vagina  or  in  any  way  altering  the  position  of  the 
patient. 

PochilicJ^rsion. — The  method  of  performing  podalic  version  varies  j^Hi«>X*-( 
with  the  nature  of  each  particular  case.  In  describing  the  operation  it  ^uxa^ 
has  been  usual  to  divide  the  cases  into  those  in  which  the  circumstances 
are  favorable  and  the  necessary  manoeuvres  easily  accomplished,  and 
those  in  which  there  are  Hkelv  to  be  considerable  difiiculties  and  in- 
creased risk  to  the  mother.  This  division  is  eminently  practicable,  since 
nothing  can  be  more  variable  than  the  circumstances  under  which  ver- 
sion may  be  required.  Before  describing  the  steps  of  the  operation  it 
may  be  well  to  consider  some  general  conditions  aj)plicable  to  all  cases 
alike. 

Position  of  the  Patient. — In  this  country  the  ordinary  position  on  the 
left  side  is  usually  employed.  On  the  Continent  and  in  America  the 
patient  js  placed  on  her  back,  with  the  legs  supported  by  assistants,  as 
in  lithotouiy.  The  former  position  is  preferable,  not  only  as  a  matter 
of  custom  and  as  involving  much  less  fuss  and  exposure  of  the  person, 
but  because  it  admits  of  both  the  operator's  hands  being  more  easily 
used  in  concert.  In  certain  difficult  cases,  when  the  liquor  amnii  has 
esca])ed  and  the  back  of  the  child  is  turned  toward  the  spine  of  the 
motii(!r,  the  dorsal  decubitus  presents  some  advantages  in  enabling  the 
hand  to  ])ass  more  readily  over  the  body  of  tlie  child  ;  but  such  cases 
are  comparatively  rare.  The  ])atient  should  be  brought  to  the  side  of 
the  bed,  across  which  she  should  be  laid  with  the  hips  ])roje(;ting  over 
and  i)ara]lel  to  the  edge,  the  knees  being  flexed  toward  the  abdonu^n  and 
separated  from  each  other  by  a  pillow  or  by  an  assistant.  Assistants 
should  also  be  placed  so  as  to  restrain  the  patient  if  necessary,  and  pre- 


462  OBSTETRIC  OPERATIONS. 

vent  her  involuntarily  starting  from  the  operator,  as  this  might  not  only 
embarrass  his  movements,  but  be  the  cause  of  serious  injury. 

Administration  of  Ancesthetics. — The  exhibition  of  anaesthetics  is 
p^cuHjy^ly^^xivantageous.  There  is  nothing  which  tends  to  facilitate  the 
steps  of  the  process  so  much  as  stillness  on  the  part  of  the  patient  and 
the  absence  of  strong  uterine  contraction.  When  the  vagina  is  very 
irritable  and  the  uterus  firmly  contracted  round  the  body  of  the  child, 
complete  anaesthesia  may  enable  us  to  effect  version,  when  without  it  we 
should  certainly  fail. 

I  Period  when  the  Operation  should  be  Undertaken. — The  most  favorable 
timejor  operating  is  when  jhe_os  is  fully  dilated,  before  or  immediately 
after  the  ruptLire__of  the  memjoranes  and,  the  discharge  of  the  liquor 
arami.  The  advantage  gained  by  operating  before  the  waters  have  es- 
caped cannot  be  overstated,  since  we  can  then  make  the  child  rotate  with 
great  facility  in  the  fluid  medium  in  which  it  floats.  In  the  ordinary 
operation,  in  which  the  hand  is  passed  into  the  uterus,  it  is  essential  to 
waitjintilthejjs  is  o_f_sufficient  size  to  admit  of  its  being  introduced 
with  safety.  This  may  generally  be  done  when  the  os  is  the  slzfi„Qf  a 
crown-piece,  especially  if  it  be  soft  and  yidding. 

Choice  of  Hand  to  be  Used. — The  practice  followed  with  regard  to  the 
hand  to  be  used  in  turning  varies  considerably.  Some  accoucheurs 
always  employ  the  right  hand,  others  the  left,  and  some  one  or  other 
according  to  the  position  of  the  child.  In  favor  of  the  right  hand  it  is 
said  that  most  practitioners  have  more  power  with  it  and  are  able  to  use 
it  with  greater  gentleness  and  delicacy.  In  transverse  jjresentations,  if 
the  abdomen  of  the  child  be  placed  anteriorly,  the  right  hand  is  said  to 
be  the  proper  one  to  use,  on  account  of  the  greater  facility  with  which 
it  can  be  passed  over  the  front  of  the  child  ;  and  in  difficult  cases  of  this 
kind,  when  we  are  operating  with  the  patient  on  her  back,  it  certainly 
can  be  employed  with  more  precision  than  the  left.  In  all  ordinary 
cases,  however,  the  left  hand  can  be  introduced  much  more  easily  in  the 
axis  of  the  passages ;  the  back  of  the  hand  adapts  itself  readily  to  the 
curve  of  the  sacrum,  and,  even  wdien  the  child's  abdomen  lies  anteriorly, 
it  can  be  passed  forward  without  difficulty  so  as  to  seize  the  feet.  These 
advantages  are  sufficient  to  recommend  its  use,  and  very  little  practice  is 
required  to  enable  the  practitioner  to  manipulate  with  it  as  freely  as  with 
the  right.  If,  in  addition,  we  remember  that  the  right  hand  is  required 
to  operate  on  the  foetus  through  the  abdominal  w'alls — and  this  is  a  point 
which  should  never  be  forgotten — we  shall  have  abundant  reasons  for 
laying  it  down  as  a  I'ldejhat  tliejgftjiand_ should  generally  be  employed. 
Before  passing  thejiand_aiid  arm  they  sliouldjbe  JreelxJjib^ 
the^ex^ptK)noFlhep{^^  whTclTTsIeft  untouched  to  admit  of  a  firm 
grasp  being  taken  of  the  foetal  limbs.  It  is  also  advisable  to  remove 
the  coat  and  bare  the  arm  as  high  as_the_elbasv. 

As  it  should  be  a  cardinal  rule  to  resort  to  the  simplest  procedure 
wdien  practicable,  it  will  be  well  to  consider  first  the  method  by  com- 
bined external  and  internal  manipulation,  without  passing  the  hand  into 
the  uterus,  and  subsequently  that  which  involves  the  introduction  of  the 
hand. 

Turning  by  Combined  External  and  Internal ^IcimjmilaMon. — To  effect 


TURNING. 


463 


podalic  version  by  the  combined  method  itjs_an_essential  preliminary  to  uiwUm^^ 
ascertain  the  situation  of  tlie  foetus  as  ^^urately  j,s  possible.      It  will  JXjuJLa^ 
generallynbe^asy  nTTrans verse  presentation  to^ialie~out  the  breech  and   — 
head  by  palpation,  while  in  head  presentations  the  fontanelles  will  show 
to  which  side  of  the  pelvis  the  face  is  turned.     The  left  hand  is  then  to 
be  passed  carefully  into  the  vagina,  in  the  axis  of  the  canal,  to  a  suf- 
ficient extent  to  admit  of  the  fingers  passing  freely  into  the  cervix.     To 
effect  this  it  is  no^  always  necessary  to  insert  the_vvhole  hand,  three  or 
four  fingers  being  generally  sufficient. 

If  the  head  lie  in  the  first  or  fourth  position,  push  it  upward  and  to  the 
left,  while  the  o^erjiand,  placed  externally  on  the  abdomen,  depresses 

Fig.  150. 


First  Stage  of  Bi-polar  Version :  Elevation  of  the  Head  and  Depression 
of  the  Breech.    (After  Barnes.) 

the  breech  toward  the  right  (Fig.  150).  By  this  means  we  act  simulta- 
neously on  both  extremities  of  the  child's  body  and  easily  alter  its 
position.  The  breech  is  pushed  down  gently  but  firmly  by  gliding  the 
hand  over  the  abdominal  wall.  The  head  will  now  pass  out  of  reach, 
and  the  shoulders  will  arrive  at  the  os  and  will  lie  on  the  tips  of  the 
fingers.  Tliis  is  similarly  pushed  upward  in  the  same  direction  as  the 
head  (Fig.  151),  the  bnsech  at  the  same  time  being  still  furtlier  de])ressed 
unt2J^t|i(!  knee  comtis  within  reach  of  tlm  fingers,  when  (the  meml)ranes 
being  nmv  ruptured,  if  still  unbroken)  it  is  seized  and  pulled  down 
through  the  os  (Fig.  152)^  Occasionally  the  foot  comes  immediately 
over  the  os,  when  it  mn  be  seized  instead  of  the  knee.  Version  may  be 
facilitated  by  (changing  the  position  of  the  external  hand  and   pusln'ng 


464 


OBSTETRIC  OPERATIONS. 


the  head  upward  from  the  iliac  fossa,  instead  of  continuing  the  attempt 
to  depress  the  breech  (Figs.  152  and  153).  These  ruanipulations  should 
ahvavs  be  carried  on  in  the  intervals,  and  desisted  from  when  the^pins 


Fig.  151. 


Second  Stage  of  Bi-polar  Version :  Elevation  of  the  Shoulders  and 
Depression  of  the  Breech.    (After  Barnes.) 

come  on  ;  and  when  the  pains  recur  with  great  force  and  frequency  the 
advantage  of  chloroform  wall  be  particularly  apparent.      In  the  second 

Fig.  152. 


Third  Stage  of  Bi-polar  Version  :  Seizure  of  the  Knee  and  Partial 
Elevation  of  the  Head.    (After  Barnes.) 

andjriiirdjDQMtiimaJlie^^^ 

head  is  pushed  upward _aiKLt£)J:lie_jight,  the  breech_downward  and.to 

thejeft.    When  the  position  cannot  be  made  out  with  certainty,  it  is  well 


TURNING. 


465 


to  assume  that  it  is  the  first,  since  that  is  the  one  most  frequently  met 
with ;  and  even  if  it  be  not,  no  great  inconvenience  is  likely  to  occur. 
If  the  OS  be  not  sufficiently  open  to  admit  of  delivery  being  concluded, 
the  lower  extremity  can  be  retained  in  its  new  position  with  one  finger 
until  dilatation  is  sufficiently  advanced  or  until  the  uterus  has  perma- 


FiG.  153. 


Fourth  Stage  of  Bi-polar  Version :  Drawing  Down  of  the  Legs 
and  Completion  of  Version.    (After  Barnes.) 

nently  adapted  itself  to  the  altered  position  of  the  child  ;  either  of  which 
results  will  generally  be  effected  in  a  short  space  of  time. 

In  transverse  presentations  the  same  jneans  are  to  be  adopted,  the 
shoulder  being  pushed  upward  in  the  direction  of  the  head,  while  the 
breech  is  depressed  from  without.  This  is  frequently  sufficient  to  bring 
the  knees  within  reach,  especially  if  the  membranes  are  entire,  but  ver- 
sion is  much  facihtatecl  by  pressing  the  head  upward  from  without, 
alternately  with  depression  of  the  breech.  If  the  liquor  amnii  has 
escaped,  and  the  uterus  is  firmly  contracted  round  the  body  of  the  child, 
it  will  be  found  impossible  to  effect  an  alteration  in  its  position  without 
the  introduction  of  the  hand,  and  the  ordinary  method  of  turning  must 
be  employed.  The  peculiar  advantage  of  the  combined  process  is  that 
it  in  no  way  interferes  with  the  latter,  for  should  it  not  succeed  the  hand 
can  be  passed  on  into  the  uterus  without  withdrawal  from  the  vagina 
(provided  the  os  be  sufficiently  dilated)  and  the  feet  or  knees  seized  and 
bnjiiglit  down. 

Podalic  Version  when  the  Hand  u  Introduced  into  the  Uterus. — jTurn-  "l-U^  ^ 
ing  with  th(;  hand  introduced  into  ^he  uterus,  j^rovidedthewa^^^  UXxX^^ 

not  or  liavc;  only  recently  escaped  and  tlie  os  be  sufficiently  dilatedjjsjin 
operation  generally  performed  with  ease. 
30  Z- 


466 


OBSTETRIC  OPERATIONS. 


Introduction  of  the  Hand. — The  first  step,  and  one  of  the  most 
important,  is  the  introduction  of  the  hand  and  arm.  The  fingers  hav- 
ing been  pressed  together  in  the  form  of  a  cone,  the  thumb  lying 
between  the  rest  of  the  fingers,  the  hand,  thus  reduced  to  the  smallest 
possible  dimensions,  issLmvh^nd_carefull^^^^  passed_into  the  vagina  in 
the  axis  of  the  outlet  in^^aiTlriterval  between  the  jgains,  and  passed 
om^^ard  in  the  sanie  cautious^  manner  and  with  a  semi-rotjitorv  motion 
untiTlFTies  entirely  within  the  vagina,  the  clirection  oFlntroduction 
being  gradually  changed  from  the  axis  of  the  outlet  to  that  of  the  brim. 
If  uterine  contractions  come  on,  the  hand  should  remain  passive  until 
they  are  over.  It  should  ever  be  borne  in_jnind  as  one  of  the  funda- 
mental_  rules_in  jjerforming  version  that  we  should  act_only  in  the 
absence_gfjiains,  and  then  with  the^jutmost  gentleness,  all  force  and 
violenjt  pushing  being  avoided.  The  hand,  still  in  the  form  of  a  cone, 
liaving  arrived  at  the  os,  if  this  be  sufficiently  dilated  may  be  passed 
through  at  once.  If  thej)sj3ejiotjjuitejjj3en,  but_dilatable,  the  points 
of  the  fingers  may  be  gently  insinuated  and  occasionally  expanded,  so 
as  to  press  it  open  sufficiently  to  permit  the  rest  of  the  hand  to  pass. 
While  this  is  being  done  the  uterus  should  be  steadied  by  the  other  hand 

Fig.  154. 


Seizure  of  the  Feet  when  the  Hand  is  Introduced  into  the  Uterus. 

placed  externally  or  by  an  assistant.  If  the  presentation  should  not 
previously  have  been  made  out  ^^'ith  accuracy,  we  can  now  ascertain 
how  to  pass  the  hand  onward,  so  that  its  palmar  surface  mav  correspond 
with  the  abdomen  of  the  child. 


TURNING. 


467 


Rupture  of  the  Membranes. — The  membranes  should  now  be  ruptured 
— ifjjpssible  during  tlie  absence  of  pain — so  as  to_^reventJ:he_jwaters 
b^ing^  forced^  out.  The  hand  and  arm  form  a  most  efficient  plug,  and 
the  liquor  amnii  cannot  escape  in  any  quantity.  Some  practitioners 
recommend  that  before  rupturing  the  membranes  the  hand  should  be 
passed  onward  between  them  and  the  uterine  walls  until  we  reach  the 
feet.  By  so  doing  we  run  the  risk  of  separating  the  placenta ;  besides, 
we  have  to  introduce  the  hand  much  farther  than  may  be  necessary, 
since  the  knees  are  often  found  lying  quite  close  to  the  os.  As_soon_as 
the  membranes  are  perforated,  the  hand  can  be  passed  on  in  search  of 

Fig.  155. 


Drawing  Down  of  the  Feet  and  Completion  of  Version. 

the  feet  (Fig.  154).  At  this  stage  of  the  operation  increased  care  is 
necessary  to  avoid  anything  like  force,  and  should  a  pain  come  on  the 
hand  must  be  kept  perfectly  flat  and  still,  and  rather  pressed  on  the 
bcxly  of  the  child  than  on  the  uterus.  If  the  pains  be  strong,  much 
inconvenience  may  be  felt  from  the  compression ;  and  were  tlie  onward 
movement  continued,  or  the  hand  even  kept  bent  in  the  conical  form  in 
which  it  was  introduced,  rupture  of  the  uterine  walls  might  easily  be 
cjiiised.  This  is  not  likely  to  occur  in  the  class  of  cases  now  under  con- 
sideration, for  it  is  chiefly  when  the  waters  have  long  escaped  that  the 
progress  of  the  hand  is  a  nuitter  of  difli(Milty.  Valuable  assistaiux;  may 
now_be  given  by  press! rig_thc  breech  downward  from  without,  so  as  to 
brjngtficknecs  or  feet  more  easily  within  the  reach  oftjic  internal  hand. 


468  OBSTETRIC  OPERATIONS. 

Having  arrived  at  the  kneeg_or  feet,  they  may  be  seized  between  the  fin- 
gers  and  drawn  downward  in  the  absence  of  a  ]3ain  (Fio;.  155).  This 
wiTTcaiise  the  foetus  to  revolve  on  its  axis,  the  breech  will  descend,  and 
at  the  same  time  the  ascent  of  the  head  may  be  assisted  by  the  right 
hand  from  without.  It  is  a  question  with  many  accoucheurs  which  part 
of  the  inferior  extremities  should  be  seized  and  brought  down.  Some 
recommend  us  to  seize  both  feet,  others  prefer  one  only,  while  some 
advise  the  seizure  of  one  or  both  knees.  In  a  simple  case  of  turning, 
before  the  escape  of  the  ^^'aters,  it  does  not  matter  much  which  of  these 
plans  is  followed,  since  version  is  accomplished  with  the  greatest  ease  by 
any  one  of  them.  The  seizure  of  the  knee,  however,  instead  of  the  feet, 
offers  certain  advantages  which  should  not  be  overlooked.  It  is  gen- 
erally more  accessible,  affords  a  better  hold  (the  fingers  being  inserted  in 
the  flexure  of  the  ham),  and,  being  nearer  the  spine,  traction  acts  more 
directly  on  the  body  of  the  child.  Any  danger  of  mistaking  the  knee 
for  the  elbow  may  be  obviated  by  remembering  the  simple  rule  that  the 
salient  angle  of  the  former  when  the  thigh  is  flexed  looks  toward  the 
head  of  the  child,  of  the  latter  toward  its  feet.  Certain  advantages  may 
also  be  gained  by  bringing  down  one  foot  or  knee  only,  instead  of  both. 
When  one  inferior  extremity  remains  flexed  on  the  body  of  the  child, 
the  part  which  has  to  pass  through  the  os  is  larger  than  when  both  legs  are 
drawn  down,  and  consequently  the  os  is  more  perfectly  dilated,  and  less 
difficulty  is  likely  to  be  experienced  in  the  delivery  of  the  rest  of  the 
body,  so  that  the  risk  to  the  child  is  materially  diminished. 

Choice  of  the  Leg  to  be  brought  doicn  in  Transverse  Presentation. — 
Simpson,  whose  views  have  been  adopted  by  Barnes  and  other  writers, 
recommends  the  seizing,  if  possible,  in  arm  presentations,  of  the  knee 
farthest  from  and  opposite  to  the  presenting  arm,  as  by  this  means  the 
body  is  turned  round  on  its  longitudinal  axis  and  the  presenting  arm 
and  shoulder  more  easily  withdrawn  from  the  os.  Dr.  Galabin  has 
carefully  investigated  this  point  in  a  recent  pajjer,^  and  contends  that 
there  is  a  greater  mechanical  advantage  in  seizing  the  leg  Avhich  is  near- 
est to,  and  on  the  same  side  as,  the  jDresenting  arm ;  and  this,  moreover, 
is  generally  more  readily  done. 

Management  of  the  Case  after  Vei-sion. — As  soon  as  the  head  has 
reached  the  fundus  and  the  lower  extremity  is  brought  through  the  os, 
the  case  is  converted  into  a  foot  or  knee  presentation,  and  it  comes  to  be 
a  question  whether  delivery  should  now  be  left^to  natiire  or  terminated 
b\"  art.  This  must  depend  to  a  certain  extent  on  the  case  itself  and  on 
the  cause  which  necessitated  version,  but  generally  it  will  be  advisable 
to_  finish  delijveiy  Mathout  unnecessary_d£lay.  To  accomplish  _jthis, 
downward  traction_is_made  diiring  the  pains,  and  desisted  from  in  the 
ijitervals  (Fig.  156).  As  the  umbilical  cord  appears,  a  loop  should_be 
drawn  do_wn ;  and  if  the  hanj]sJbejibo\^e  the  head,  they  must  bejlisen- 
gaged  and  brought  over  the  face  in  the  same  manner  as  in  an  ordinary 
footling  presentation.  The  management  of  the  head  after  it  descends 
into  the  cavity  of  the  pelvis  must  also  be  conducted  as  in  labors  of  that 
description. 

Turning  in  Placenta  Pra^ria. — In  cases  of  placenta  prsevia  the  os  will, 

1  Obst.  Trans.,  vol.  xix  ,  1877. 


TURNING. 


469 


as  a  rule,  be  more  easily  dilatable  than  in  transverse  presentations. 
Hicks'  method  offers  the  great  advantage  of  enabling  us  to  perform 
version  much  sooner  than  was  formerly  possible,  since  it  only  requires 
the  introduction  of  one  or  two  fingers  into  the  os  uteri.  Should  we  not 
succeed  by  it,  and  the  state  of  the  patient  indicates  that  delivery  is  neces- 
sary, we  have  at  our  command  in  the  fluid  dilators  a  means  of  artificially 
dilating  the  os  uteri  which  can  be  employed  with  ease  and  safety.  If 
we  have  to  do  with  a  case  of  entire  placenta_L^resentation,  the  hand 
should  be  passed  at  that  point  where  the  placenta  seems  to  be  least 
attached.     This  will  always  be  better__than  attempting  to  perforate  its  siJi-'U^ 

Fig.  156.  ii.^A^u'^  lu    irn^  ^u~^  lAjt^ 

Ol/i-^^A^       t/VA^'^*-^    iA^ir\^^v^    t^  ru^l 


Showing  the  Completion  of  Version.    (After  Barnes.) 

.substance — a  measure  sometimes  recommended,  but  more  easily  per- 
formed in  theory  than  in  practice.  If  the  placenta  only  partially 
present,  the  hand  should,  of  course^  be  inserted  at  its  free  border!  It 
will  frequently  be  advisable  not  to  hasten  delivery  after  the  feet  have 
been  brought  through  tlic  os,  for  they  form  of  themselves  a  very  efficient 
plug  and  effectually  ])revent  further  loss  of  blood ;  while,  if  the  patient 
be  much  exhausted,  she  may  have  her  strength  recruited  by  stimulants, 
etc.  before  the  completion  of  delivery. 

Twrninrj  in  Ahdmiiino-anterior  Pofiition.s. — In  abdoinino-anterior  posi- 
tions in  which  the  waters  have  escaped,  and  in  which,  therefore,  some 
difficulty  may  be  reasonably  ;Hiti('ij)ated,  th(!  operation  is  generally  more 
easily  |)('rform(id  with  the  piificnt  on  her  back  ;  the  ri<i;ht  hand  is  then 
introchiccd  into  the  idcriis   and  the  left  employed  externally  (Fig.  157). 


470  OBSTETRIC  OPERATIONS. 

In  this  way  the  internal  hand  has  to  be  passed  a  shorter  distance  and  in 
a  less  constrained  position.  The  operator  then  sits  in  front  of  the 
patient,  who  is  supported  at  the  edge  of  the  bed  in  the  lithotomy  position 

Fig.  157. 


Showing  the  Use  of  the  Right  Hand  in  Abdomino-anterior  Position. 

with  the  thighs  separated,  and  the  right  hand  is  passed  up  behind  the 
pubes  and  over  the  abdomen  of  the  child. 

Difficult  Cases  of  Arm  Presentation. — The  difficulties  of  tumijig^nil- 
ininate  in  those  unfavorable  cases  of  ami  presentation  in  which  the  mem- 
branes have  been  long  ruptured,  the  shoulder  and  arinpressed  down 
intojthejjelyis,  and  the  uterus  contracted  round  the^^body^of  jtlie_child. 
The  uterus  being  firmly  and  spasmodically  contracted,  the  attempt  to 
introduce  the  hand  often  only  makes  matters  worse  by  inducing  more 
frequent  and  stronger  pains.  Even  if  the  hand  and  arm  be  successfully 
passed,  much  difficulty  is  often  exj^erienced  in  causing  the  body  of  the 
child  to  rotate ;  for  we  have  no  longer  the  fluid  medium  present  in 
which  it  floated  and  moved  with  ease,  and  the  arm  of  the  operator  may 
be  so  cramped  and  pained  by  the  pressure  of  the  uterine  walls  as  to  be 
rendered  almost  powerless.  The  risk  of  laceration  is  also  greatly  in- 
creased, and  the  care  necessary  to  avoid  so  serious  an  accident  adds  much 
tothe  difficulty_Q£_the  operation. 

Value  of  Ancesthesia  in  Relaxing  the  Uterus. — In  these  perplexing 
cases  various  expedients  have  been  tried  to  cause  relaxation  of  the  spas- 
modically contracted  uterine  fibres,  such  as  copious  venesection  in  the 
erect  attitude  until  fainting  is  induced,  warm  baths,  tartar  emetic,  and 
similar  depressing  agents.  None  of  thfise,  however,  are  so  useful  as  the 
free  administration  of  chloroform^  which  has  practically  superseded  them 
all,  and  often  answers  most  effectually  when  given  to  its  full  surgical 
extent. 


TURNING.  471 

Mode  of  Procedure. — The  hand  must  be  introduced  with  the  precau- 
tions already  described.  If  the  arm  be  completely  protruded  into  the 
vagina,  we  should  pass  the  hand  alono;  it  as  a  guide,  and  its  palmar  sur- 
face will  at  once  indicate  the  position  of  the  child's  abdomen.  No  ad- 
vantage is  gained  by  amputation,  as  is  sometimes  recommended.  When 
the  OS  is  reached  the  real  difficulties  of  the  operation  commence,  and,  if 
the  shoulder  be  firmly  pressed  clown  into  the  brim  of  the  pelvis,  it  may 
not  be  easy  to  insinuate  the  hand  past  it.  It  is  allowable  to  repress  the 
presenting  part  a  little,  but  with  extreme  caution,  for  fear  of  injuring 
the  contracted  uterine  parietes.  It  is  better  to  insinuate  the  hand  past 
the  obstruction,  which  can  generally  be  done  by  patient  and  cautious 
endeavors.  Having  succeeded  in  passing  the  shoulder,  the  hand  is  to 
be  pressed  forward  in  the  intervals,  being  kept  perfectly  flat  and  still  on 
the  body  of  the  foetus  when  the  pains  come  on.  It  is  much  safer  to 
press  on  it  than  on  the  uterine  walls,  Avhich  might  readily  be  lacerated 
by  the  projecting  knuckles.  When  the  hand  has  advanced  sufficiently 
far,  it  will  be  better,  for  the  reasons  already  mentioned,  to  seize  and 
bring  down  one  knee  only. 

Management  of  Cases  in  wkich  the  Foot  is  brought  down,  but  the  Fcetus 
will  not  Revolve. — Even  when  the  foot  has  been  seized  and  brought 
thiwigh_the_os^  it  is  by  no  means  always  easy  to  make  the  child  revolye 
on  its  axis,  as  the  shoulder  is  often  so  firmly  fixed  in  the  pelvic  brim  as 
not  to  rise  toward  the  fundus.  Some  assistance  may  be  derived  from 
pushing  the  head  upward  from  without,  which,  of  course,  would  raise 
the  shoulder  along  with  it.  If  this  should  fail,  we  may  effect  our  object 
by  passing  a_noose  of  tape  or  wire  ribbon  round  the  liinli,  byjyhich 
traction  is  made  downward  and  backward ;  at  the  same  time  the  other 
hjind^is  passed  into  the  vagina  to  displace  the  shoulder  and  push  it  out 
of  the  brim.  It  is  evident  that  this  cannot  be  done  as  long  as  the  limb 
is  held  by  the  left  hand,  as  there  is  no  room  for  both  hands  to  pass  into 
the  vagina  at  the  same  time.  By  this  manoeuvre  version  may  be  often 
completed  when  the  foetus  cannot  be  turned  in  the  ordinary  way. 
Various  instruments  have  been  invented,  both  for  passing  a  lac  round 
the  child's  limb  and  for  repressing  the  shoulder,  but  none  of  them 
can  compete,  either  in  facility  of  use  or  safety,  with  the  hand  of  the  ac- 
coucheur. 

If  all  Attempts  at  Version  Fail,  Mutilation  of  the  Foetus  is  Necessary. — 
Should  all  attempts  at  version  fail,  no  resource  is  left  but  the  mutilation 
of  the  child,  cither  by  evisceration  or  decapitation.  This  extreme  meas- 
ure is,  fortunately,  seldom  necessary,  as  with  due  care  version  may  gen- 
erally be  effected,  even  under  the  most  unfavorable  circumstances. 


472  OBSTETRIC  OPERATIONS. 


CHAPTER    III. 

THE  FORCEPS. 

Of  all  obstetric  operations,  the  most  important,  because  the  most  truly 
conservative  both  to  the  mother  and  child,  is  the  application  of  the  for- 
cej)s.  In  modern  midwifery  the  use  of  the  instrument  is  much  extended, 
and  it  is  now  applied  by  some  of  our  most  experienced  accoucheurs  Avith 
a  frequency  which  older  practitioners  would  have  strongly  reprobated. 
That  the  injudicious  and  unskilful  use  of  the  forceps  is  capable  of  doing 
much  harm  no  one  will  for  a  moment  deny.  This,  however,  is  not  a 
reason  for  rejecting  the  recommendation  of  those  who  advise  a  more 
frequent  resort  to  the  operation,  but  rather  for  urging  on  the  practitioner 
the  necessity  of  carefully  stud}dng  the  manner  of  performing  it,  and  of 
making  himself  familiar  with  the  cases  in  which  it  is  easy  or  the  reverse. 
Nothing  but  practice — at  first  on  the  manikin,  and  afterward  in  actual 
cases — can  impart  the  operative  dexterity  which  it  should  be  the  aim  of 
every  obstetrician  to  acquire,  and  without  which  there  can  be  no  assur- 
ance of  his  doing  his  duty  to  his  patient  efficiently. 

Description  of  the  Instrument. — The  forceps  may  best  be  described  as 
a  pair  of  artificial  hands  by  which  the  foetal  head  may  be  grasped  and 
drawn  through  the  maternal  passages  by  a  vis  a  fronte  when  the  vis  a 
tergo  is  deficient.  This  descrijjtion  will  impress  on  the  mind  the  im- 
portant action  of  the  instrument  as  a  tractor,  to  which  all  its  other 
powers  are  subservient.  The  forceps  consists  of  two  separate  blades 
of  a  curved  form  adapted  to  fit  the  child's  head,  a  lock  by  which  the 
blades  are  united  after  introduction,  and  handles  which  are  grasped 
by  the  operator  and  by  means  of  which  traction  is  made.  It  would 
be  a  wearisome  and  unsatisfactory  task  to  dwell  on  all  the  modifications 
of  the  instrument  which  have  been  made,  which  are  so  numerous  as  to 
make  it  almost  appear  as  if  no  one  could  practise  midwifery  with  the 
least  pretension  to  eminence  unless  he  has  attached  his  name  to  a  new 
variety  of  forceps. 

The  Short  Forceps. — The  original  instrument,  invented  by  the  Cham- 
berlens,  may  be  looked  upon  as  the  type  of  the  short  straight  forceps, 
which  has  been  more  employed  than  any  other,  and  which  perhaps 
finds  its  best  representative  in  the  short  forceps  of  Denman  (Fig.  158). 
Indeed,  the  only  essential  difference  betAveen  the  two  is  the  lock  of  the 
latter,  originally  invented  by  Smellie,  which  is  so  excellent  that  it  has 
been  adopted  in  all  British  forceps,  and  which,  for  facility  of  juncture, 
is  much  superior  to  either  the  French  pivot  or  the  German  lock,  while 
for  firmness  it  is,  for  all  practical  purposes,  as  good  as  either.  In  this 
instrument  the  blades  are  7,  the  handles  4f ,  inches  in  length ;  the  extremi- 
ties of  the  blades  are  exactly  1  incli  apart,  and  the  space  between  them 
at  their  widest  part  is  2|^  inches.  The  blades  measure  1|-  inches  at  their 
greatest  breadth,  and  spring  with  a  regular  sweep  directly  from  the  lock, 


THE  FORCEPS. 


473 


Fig.  158. 


there  being  no  shank.  The  blades  are  formed  of  the  best  and  most 
highly-tempered  steel  to  resist  the  strain  to  which  they  are  occasion- 
ally subjected,  and  they  are  smooth  and 
rounded  on  their  inner  surface  to  obviate 
the  risk  of  injury  to  the  scalp  of  the 
child. 

Advantage  Claimed  for  this  Form 
of  Instrument. — The  special  advantage 
claimed  for  this  form  of  instrument  is 
that,  the  two  halves  being  precisely  simi- 
lar, no  care  or  forethought  is  required  on 
the  part  of  the  practitioner  as  to  which 
blade  should  be  introduced  uppermost — 
an  advantage  of  no  great  value,  since  no 
one  should  undertake  a  case  of  forceps 
delivery  who  has  not  sufficient  know- 
ledge of  the  of)eration  and  presence  of 
mind  enough  to  obviate  any  risk  from 
the  introduction  of  the  wrong  blade 
first.  On  account  of  its  shortness  and 
the  want  of  the  second  or  pelvic  curve, 
it  js^onlyadapted  for  cases  in  which  the 
head  is  low  down^n_tli^jpelyis_or^actu- 
ally_j;^estm^]oiPth^_^^ 

The  Pelvic  Carve:  its  Advantages. —  /  q 

The  question  of  the  second  or  pelvic 
curve  is  one  on  which  there  is  much 
diiference  of  opinion.  The  forceps  we 
are  now  considering — and  the  many  modifications  formed  on  the  same 
plan — is  constructed  solely  with  reference  to  its  grasp  on  the  child's 
head,  and  without  regard  to  the  axes  of  the  maternal 
passages.  Consequently,  were  we  to  introduce  it  when 
the  head  was  at  the  upper  part  of  the  pelvis,  we  could 
not  fail  to  expose  the  soft  parts  to  the  risk  of  contusion 
and  (in  consequence  of  the  necessity  of  drawing  more 
directly  backward)  unduly  stretch  and  even  lacerate  the 
perineum.  Hence  it  is  now  admitted  by  obstetricians, 
with  few  exceptions,  that  the^  second  curve  is  essential 
befoi-e  the  comjjlete  descent  of  the  head,  although  it  is 
not  absolutely  so  after  this  has  taken  place.  The  only 
circumstances  under  which  a  straight  blade  can  possess 
any  superiority  are  in  certain  cases  of  occipito-posterior 
position  in  which  it  is  found  necessary  to  rotate  the  head 
round  a  largo  extent  of  the  ])elvis,  wlien  the  cin-ular 
sweep  of  a  strongly-curved  instrument  might  prove 
injiwious.  Such  cases,  however,  are  of  rare  ()C(!ur- 
rence,  and  need  in  no  way  influence  the  general  em- 
ployment of  the  ])elvi(;  curve. 

Ziajler^H  Forceps. — The  short  forceps  usually  em]iloyed  in  Scotland  is 
the  invention  of  the  late  I)i".  Zicgl(!r  (Fig.  1 '^>''),  and  is  useful  from  the 


Denman's  Short  Forceps. 


Fig.  159. 


Zicglcr's  Forceiis. 


474 


OBSTETRIC  OPERATIONS. 


Fig.  160. 


facility  with  wliich  the  blades  may  be  introduced  in  accurate  apposition 
to  each  other — a  point  which  in  practice  is  of  no  little  value.  In  g;en- 
eral  size  and  appearance  it  closely  resembles  Denman's  forcep.s,  but  the 
fenestrum  of  the  lower  blade  is  continued  down  to  the  handle.  In 
introducing,  the  lower  blade  is  slipped  over  the  handle  of  the  other 
blade,  already  in  situ,  arid  thus  it  is  guided  with  great  certainty  into  a 
proper  position,  locking  itself  as  it  passes  on.  This  instrument  has  the 
disadvantage  of  not  having  the  second  curve,  but  the  facility  of  intro- 
duction has  rendered  it  a  great  favorite  with  many  who  have  been  in  the 
habit  of  employing  it. 

The  Long  Forceps. — For  cases  in  which  the  head  is  not  on  the  peri- 
neum, or  at  least  not  quite  low  in  the  pelvis,  a  longer  instrument  is  essen- 
tial. To  meet  this  indication  Smellie  invented  the  long  forceps,  which, 
like  the  shorter  instrument,  has  been  very  variously  modified.  The  most 
perfect  instrument  of  the  kind  employed  in  this  country  is  that  known 
as  Simpson's  forceps  (Fig.  160),  which  combines  many  excellent  points 
selected  from  the  forcej)S  of  various  obstetricians,  as  well  as  some  original 
additions,  and  which,  as  a  whole,  has  never  been  surpassed  until  Tarnier's 
or  its  modification  was  invented.  The  curved  portions  of  the  blades  are 
6^  inches  long,  the  fenestrum  measuring  1^  at  its  widest  part.     The 

extremities  of  the  blades  are  1  inch 
asunder  when  the  handles  are  closed, 
and  3  inches  at  their  widest  part.  The 
object  of  this  somewhat  unusual  M'idtli 
is  to  lessen  the  compressing  power  of  the 
instrument  without  in  any  way  interfer- 
ing with  its  action  as  a  tractor.  The 
pelvic  curve  is  less  than  in  most  long 
forceps,  so  as  to  admit  of  the  rotation  of 
the  head,  when  necessary,  without  the 
risk  of  injuring  the  maternal  structures. 
Between  the  curve  of  the  blade  and 
the  lock  is  a  straight  portion  or  shank 
measuring  2|^  inches,  which,  before 
joining  the  handle,  is  bent  at  right 
angles  into  a  knee.  This  shank  is  a 
useful  addition  to  all  forceps,  and  is 
essential  in  the  long  forceps  to  ensure 
the  junction  of  the  blades  beyond  the 
parts  of  the  mother,  which  might  other- 
wise be  caught  in  the  lock  and  injured. 
The  knees  serve  the  purpose  of  pre- 
venting the  blades  from  slipping  from 
each  other  after  they  have  been  united. 
They  also  admit  of  one  finger  being 
introduced  above  the  lock  and  used  as 
an  aid  in  traction — a  provision  ^hich 
is  made  in  some  other  varieties  of  long 
forceps  by  a  semicircular  bend  in  each  shank.  The  handles,  which  in 
most  British  forcejDS  are  too  small  and  smooth  to  afibrd  a  firm  grasp,  are 


Simpson's  Forceps. 


THE  FORCEPS.  475 

serrated  at  the  edge  and  flattened  from  l:)efore  backward,  so  as  to  fit  the 
closed  fist  more  accurately.  At  their  extremities,  near  the  lock,  there 
are  a  pair  of  projecting  rests,  over  which  the  fore  and  middle  fingers 
may  be  passed  in  traction,  and  which  greatly  increase  our  power  over 
the  instrument.  Although  this  and  other  varieties  of  the  long  forceps 
are  specially  constructed  for  application  when  the  head  is  high  in  the 
pelvis,  it  answers  quite  as  well  as  the  short  forceps — indeed,  in  most 
respects  better — when  the  head  has  descended  low  down.  It  is  a  decided 
advantage  for  the  practitioner  to  habituate  himself  to  the  use  of  one 
instrument,  with  the  application  and  power  of  which  he  becomes  thor- 
oughly familiar.  It  is  a  mere  waste  of  space  and  money  for  him  to 
encumber  himself  with  a  number  of  instruments  of  various  shapes  and 
sizes ;  and  he  may  be  sure  that  a  good  pair  of  long  forceps  will  be  suit- 
able for  every  emergency  and  in  any  position  of  the  head. 

Disadvantages  of  a  Weak  Instrument. — The  chief  argument  agai-nst 
the  use  of  such  an  instrument  in  simple  cases  is  its  great  power.  This, 
however,  is  entirely  based  on  a  misconception.  The  existence  of  power 
does  not  involve  its  use,  and  the  stronger  instrument  can  be  employed 
with  quite  as  much  delicacy  and  gentleness  as  the  weaker.  The  remarks 
of  Dr.  Hodge  ^  on  this  point  are  extremely  apposite  and  are  well  worthy 
of  quotation.  He  says  :  "  Certainly,  no  man  ought  to  apply  the  forceps 
who  has  not  sufficient  discretion  to  use  no  more  force  than  is  absolutely 
requisite  for  safe  delivery.  If,  therefore,  there  is  more  power  at  com- 
mand, he  is  not  obliged  to  use  it ;  while,  on  the  contrary,  \f  much  power 
be  demanded,  he  can,  within  the  bounds  of  prudence,  exercise  it  by  the 
long  forceps,  but  with  the  short  forceps  his  efforts  might  be  luiavailing. 
Moreover,  in  cases  of  difficulty,  the  short  forceps  being  used,  the  prac- 
titioner would  be  forced  to  make  great  muscular  efforts  ;  while  with  the 
long  forceps,  owing  to  the  great  leverage,  such  effort  will  be  compara- 
tively trifling,  and  of  course  the  wliole  force  demanded  can  be  much 
more  delicately,  and  at  the  same  time  efficiently,  applied,  and  with  more 
safety  to  the  tissues  of  the  child  and  its  parent." 

Continental  Forceps. — The  forceps  usually  employed  on  the  Continent 
and  in  America  differs  considerably,  both  in  appearance  and  construc- 
tion, from  those  in  use  in  this  country.  As  a  rule,  it  is  a  larger  and 
more  powerful  instrument,  joined  by  a  pivot  or  button  joint,  and  it 
ah^ays  possesses  the  second  or  pelvic  curve.  Of  late  years  Simpson's 
forceps  has  been  much  employed  in  some  parts  of  Germany.  The  chief 
objection  to  the  continental  instruments  is  their  cumbrousness.  This  is 
chiefly  in  the  handles,  which  in  many  of  them  are  forged  in  a  piece 
with  the  blades,  the  part  introduced  within  the  maternal  structiu^es  not 
being  materially  different  from  the  corresponding  part  of  the  English 
instrument. 

Tarnier's  Forceps. — Tlic  forceps  invented  by  Prof  Ttirnicr  (Fig.  161) 
has  recently  attracted  considerable  attention.  In  this  instrument  trac- 
tion is  not  mad(!  on  the  handles  by  which  the  blades  are  introduced,  as 
in  ordinary  force|)s,  but  on  a  supplementary  handle  (a)  subsequently 
attached  to  the  blades  near  the  lower  opening  of  the  fenestnc  (h).  The 
object  claimed  for  this  arrangement  is  that  less  force  is  required  in  trac- 

'  SyKtevi  (if  (JhtilclricK,  |).  lil'J. 


476 


OBSTETRIC  OPERATIONS. 


tion,  which  can  always  be  made  in  the  proper  axis  of  the  pelvis ;  that 
the  blades  are  not  likely  to  slip ;  and  that  rotation  of  the  head  is  not 
interfered  with.  The  handles  of  the  forceps,  moreover,  guide  the  opera- 
tor to  the  direction  in  which  he  ought  to  pull,  since  all  that  is  required 
is  to  keep  the  traction-rods  parallel  to  them.  This  instrument,  however, 
although  theoretically  perfect,  is  somewhat  too  complicated  for  gen- 
eral use. 

Simpson's  Axis-Traction  Forceps. — Professor  Simpson  of  Edinburgh 
has  invented  a  modification  of  Tarnier's  instrument,  which  he  calls  the 


Fig.  161. 


Fig.  162. 


Tarnier's  Forceps. 


Simpson's  Axis-Traction  Forceps. 
a,  h.  Traction  handle,    e,  /.  Line  of  traction. 


"axis-traction  forceps"  (Fig.  162).  The  supplementary  handles  are 
fixed  to  the  blades,  and  the  whole  mechanism  is  much  simpler  than  in 
Tarnier's  forceps.  Dr.  Simpson  reports  very  favorably  of  this  forceps, 
and  it  is  certainly  well  adapted  for  the  object  aimed  at.  For  some  years 
I  have  used  it  extensively,  and  have  every  reason  to  be  satisfied  with  it, 
especially  in  the  high  forceps  operation,  in  which  it  seems  to  me  superior 
to  any  other  instrument. 

Action  of  the  Instrument. — The  forceps  is  generally  said  to  act  in 
thi'ee  different  ways  : 

1st.  ^.s  a  tractor  ; 

2d.  As  a  lever  ; 

3d.  As  a  compressor. 

The  Chief  Use  of  the  Forceps  is  as  a  Tractor. — It  is  more  especially 
as  a  tractor  that  the  histrument  is  of  :yalue,  and  it  is  used  with  the 
greatest  advantage  when  it  is  employed  merely  to  supplement  the  action 
of  the  uterus,  which  is  insufficient  of  itself  to  effect  delivery,  or  when, 
from  some  complication,  it  is  necessary  to  complete  labor  with  greater 
rapidity  than  can  be  accomplished  by  the  unaided  powers  of  nature.     In 


THE  FORCEPS.  477 

most  cases  traction  alone  is  sufficient ;  but  in  order  that  it  may  act  satis- 
factorily, and  that  the  instrument  may  not  slip,  a  proper  construction 
of  the  forceps  and  a  sufficient  curvature  of  the  blades  are  essential.  Tlie 
want  of  these  is  the  radical  fault  of  many  of  the  short,' straight  instru- 
ments in  common  use,  which  have  a  tendency  to  slip  during  our  efforts 
at  extraction. 

As  a  Lever. — The  forceps  acts  also  as  a  lever,  but  this  action  has  been 
greatly  exaggerated.  It  is  generally  described  as  a  lever  of  the  first 
class,  the  power  being  at  the  handles,  the  fulcrum  at  the  lock,  and  the 
weight  at  the  extremities.  There  may  possibly  be  some  leverage  power 
of  this  kind  when  the  instrument  is  first  introduced  and  the  handles 
held  so  loosely  that  one  blade  is  able  to  work  on  the  other.  But,  as 
ordinarily  used,  the  handles  are  held  with  a  sufficiently  firm  grasp  to 
prevent  this  movement,  and  then  the  two  blades  practically  form  a  single 
instrument. 

Galabin,  who  has  studied  this  subject  in  detail,  points  out^  that — "  1. 
The  lever  is  formed  by  both  blades  of  the  forceps  and  the  foetal  head 
united  in  one  immovable  mass.  As  soon  as  the  blades  begin  to  slip  over 
the  head  the  lever  is  decomposed,  and  the  swaying  movement  ceases  to 
have  any  mechanical  advantage.  2.  The  power  is  applied  to  the  handles 
in  a  slanting  direction.  The  resistance  or  weight  does  not  act  at  a  point 
either  between  the  former  and  the  fulcrum  or  beyond  the  fulcrum,  but 
at  a  point  in  a  plane  nearly  at  right  angles  to  the  line  joining  these  two 
points,  and  its  direction  is  a  line  perpendicular  to  that  plane  of  the  pel- 
vis in  which  the  greatest  section  of  the  head  is  engaged ;  that  is  to  say, 
in  the  case  of  straight  forceps  nearly  parallel  to  the  handles.  The  lever 
formed  does  not,  therefore,  strictly  speaking,  belong  to  any  one  of  the 
three  orders  into  which  levers  are  commonly  divided.  3.  The  fulcrum 
is  fixed  partly  by  friction,  partly  by  the  combination  of  traction  with 
oscillatory  movements — in  other  words,  by  the  power  being  directed  in 
great  measure  downward  and  only  slightly  to  one  side." 

He  further  shows  that  the  pendulum  motion  of  the  forceps  is  super- 
fluous in  all  ordinary  forceps  operations  in  which  traction  alone  is  amply 
sufficient  for  delivery,  but  that  when  the  head  is  impacted  and  great 
force  is  required  for  its  extraction,  a  mechanical  advantage  may  be  gained 
from  having  recourse  to  an  oscillatory  movement,  which  should,  ho-w- 
ever,  be  very  limited,  and  only  continued  if  found  to  effect  distinct 
advance  of  the  head. 

A»  a  Compressor. — Regarding  the  compressive  power  of  the  instru- 
ment tlicre  has  been  much  difference  of  opinion.  There  is  no  doubt 
that  tlie  forceps,  especially  some  of  the  foreign  instruments  in  which  the 
points  nearly  a]i]:»roach  each  other,  is  cajiable  of  exerting  considerable 
compression  on  the  head.  It  is,  however,  extremely  problematical  if 
this  action  be  of  real  value.  It  is  to  be  borne  in  mind  that  in  cases  of 
protra(!ted  labor  the  head  has  been  already  moulded  and  compressed,  and 
the  ])ones  have  been  made  to  overlap  each  other  to  their  utmost  extent, 
by  the  sides  of  the  ])e]vis.  Wc  can  s(!arc('ly,  therefore,  ex])ect  to  dimin- 
ish the  head  much  more  by  the  forc(!])s  without  ('ni])l()ying  an  amount  of 

'  fi;ilal)in,  "yVction  of  Midwifery  Forceps  as  a  Lever,"  Obsletrirjd  Jourmtl,  November, 
187G. 


478  OBSTETRIC  OPERATIONS. 

force  that  will  seriously  endanger  the  life  of  the  child.  It  is  in  cases  of 
disproportion  between  the  head  and  the  pelvis,  depending  on  slight 
antero-postcrior  contraction  of  the  pelvic  brim,  that  diminution  of  the 
child's  head  by  compression  would  be  most  useful.  Then,  however,  the 
pressure  of  the  forceps  is  exerted  on  that  portion  of  the  head  which  lies 
in  the  most  roomy  diameter  of  the  pelvis,  where  there  is  no  \^'ant  of 
space.  If  this  pressure  do  not  increase  the  opposite  diameter,  which  is 
in  apposition  to  the  narrower  portion  of  the  pelvis,  it  can  at  least  do 
nothing  toward  lessening  it,  and  diminution  of  any  other  part  of  the 
child's  head  is  not  required. 

Dynamical  Action  of  the  Forceps. — The  mere  introduction  of  the  for- 
ceps sometimes  excites  increased  uterine  action  through  the  reflex  irri- 
tation induced  by  the  j^resence  of  a  foreign  body  in  the  vagina.  This 
has  been  called  the  dynamical  action  of  the  forceps,  but  it  cannot  be 
looked  upon  in  any  other  light  than  that  of  an  occasional  accidental 
result. 

The  circumstances  indicating  the  use  of  the  forceps  have  been  sepa- 
rately considered  elsewhere,  and  to  recapitulate  them  here  would  only 
lead  to  needless  repetition.  I  shall  therefore  no^v^  merely  describe  the 
mode  of  using  the  instrument. 

Difference  between  the  High  and  Low  Operations. — Before  doing  so  it 
is  well  to  repeat  what  has  already  been  said  as  to  the  difference  between 
what  may  be  termed  the  high  and  low  forceps  operations.  The_a[ppli- 
cation  of  the  instrument  when  the  head  is  lowm  the  pelvis  is  extremely 
siTnpIeTand^wIieir'there  is  no  disproportion  between  the  head  and  the 
pelvis,  and  some  slight  traction  is  alone  required  to  supplement  deficient 
expulsive  power,  the  operation  in  the  hands  of  any  ordinary  well-in- 
structed practitioner  ought  to  be  perfectly  safe  both  to  the  mother  and 
child.  It  is_\^erv  different  when  the  head  js^arrested  at  the  brim  or  higli 
in  thepelyis.  Then  the  application  of  the  forceps  is  an  operation  requir- 
ing much  dexterity  for  its  proper  performance,  and  must  never  be  under- 
taken without  anxious  consideration.  It  is  because  these  two  classes  of 
operations  have  been  confused  that  the  use  of  the  instrument  is  regarded 
by  many  with  such  unreasonable  dread. 

Preliminary  Considerations. — Before  attempting  to  introduce  the  for- 
ceps there  are  several  points  to  which  attention  should  be  directed  : 

1st.  The  membranesjuust,  of  course,  be  ruptu_red. 

2dly.  For  the  safe  and  easy  application  of  the  instrument  it  is  also 
advisable  that  the  os  should  be  fully  dilated  and  the  cervix  retracted 
oyer  the  head.  Still,  these  two  points  cannot  be  regarded,  as  many 
have  laid  down,  as  being  sine  qud  non.  Indeed,  we  are  often  compelled 
to  use  the  instrument  when,  although  the  os  is  fully  dilated,  the  rim  of 
the  cervix  can  be  felt  at  some  point  of  the  contour  of  the  head,  espe- 
cially in  cases  in  which  the  anterior  lip  is  jammed  between  the  head  and 
the  pubes.  Provided  due  care  be  taken  to  guard  the  cervical  rim  Avith 
the  fingers  of  one  hand  as  the  instrument  is  slipped  past  it,  there  need 
be  no  fear  of  injury  from  this  cause.  If  the  os  be  not  fully  dilated,  but 
is  sufficiently  open  to  admit  of  the  passage  of  the  forceps,  the  operation, 
under  urgent  circumstances,  may  be  quite  justifiable,  but  it  must  neces- 
sarily be  a  some^^'hat  anxious  one. 


THE  FORCEPS.  479 

3dly.  The  position  of  the  head  should  be  accurately  ascertained  by 
means  of  the  sutures  and  fontanelles.  Unless  this  be  done,  the  opera- 
tion will  always  be  haphazard  and  unsatisfactory,  as  the  practitioner  can 
never  be  in  possession  of  accurate  knoMdedge  of  the  progress  of  the  case. 
It  niay  be  that  the  occiput  is  directed  backward,  and,  although  that  does 
not  contraindicate  the  application  of  the  forceps,  it  involves  special  pre- 
cautions being  taken. 

4thly.  The  bladder  and  bowels  should  be  emptied. 

Question  of  Administering  Ancesthetics. — Before  proceeding  to  operate 
the  question  of  anaesthesia  Avill  arise.  In  any  case  likely  to  be  difficult 
it  is  of  the  greatest  assistance  to  have  the  patient  completely  under  the 
influence  of  an  anaesthetic  to  the  surgical  degree,  so  as  to  have  her  as  still 
as  possible ;  but,  whenever  this  is  deemed  necessary,  another  practitioner 
should  undertake  the  responsibility  of  the  administration.  In  simple 
cases  I  believe  it  is  better  to  dispense  with  anaesthetics  altogether — partly 
because  they  are  apt  to  stop  wdiat  pains  there  are,  which  is  in  itself  a 
disadvantage,  but  chiefly  because  under  partial  anaesthesia  the  patient 
loses  her  self-control,  is  restless,  and  twists  herself  into  awkward  posi- 
tions, which  give  rise  to  the  utmost  difiiculty  and  inconvenience  in  the 
use  of  the  instrument.  Moreover,  if  no  anaesthetic  be  given  the  patient 
can  assist  the  operator  by  placing  herself  in  the  most  convenient  attitude. 

Description  of  the  Operation. — In  describing  the  method  of  applying 
the  forceps  I  shall  assume  that  we  have  to  do  with  the  simpler  variety 
of  the  operation,  when  the  head  is  low  in  the  pelvis.  Subsequently  I 
shall  point  out  the  peculiarities  of  the  high  operation. 

Position  of  the  Patient. — As  to  the  position  of  the  patient,  I  believe 
there  can  be  no  doubt  of  the  superiority  of  that  which  is  usually  adopted 
in  this  country.  On  the  Continent  and  in  America  the  forceps  is  always 
employed  with  the  patient  lying  on  her  back — a  position  involving  much 
needless  exposure  of  the  person  and  requiring  more  assistance  from  others. 
In  certain  cases  of  unusual  difficulty  the  position  on  the  back  is  of  un- 
questionable utility,  but  we  may  at  least  commence  the  operation  in  the 
usual  way,  and  subsequently  turn  the  patient  on  her  back  if  desirable. 

Importance  of  Suitable  Position. — Much  of  the  facility  wdth  which  the 
blades  are  introduced  depends  on  the  patient's  being  properly  placed. 
Hence,  although  it  gives  rise  to  a  little  more  trouble  at  first,  t  believe 
that  it  is  always  best  to  pay  particular  attention  to  this  point,  whether 
the  high  or  low  forceps  operation  be  about  to  be  performed.  The  patient 
should  be  brought  quite  to  the  side  of  the  bed,  with  her  nates  parallel  to 
and  projecting  somewhat  over  its  edge.  The  body  should  lie  almost 
dii-(.'ctly  across  the  bed,  and  nearly  at  right  angles  to  the  hips,  with  the 
knees  raised  toward  the  abdomen  (Fig.  163).  In  this  way  there  is  no 
risk  of  the  handle  of  the  ujiper  blade,  when  depressed  in  introduction, 
coming  in  contact  with  the  bed. 

The  ljlad(!s  should  be  warmed  in  te])id  water,  lubricated  Mnth  cold 
cream  or  carbolit;  oil,  and  pla(;ed~ ready  to  JiancU 

These  pr(;b'ininari('s  having  been  attended  to,  we  proceed  to  the  intro- 
duction of  the  bhidcs,  sitting  by  the  side  of  tlu;  bed  op|)Ositc  the  nates  of 
the  patient. 

Direction  in  which  fhc  B/adcs  arc  lo  he  Jiitrodaccd. — "^fhe  important 


480 


OBSTETRIC  OPERATIONS. 


question  now  arises,  In  ^vhat  direction  are  the  l)lacles  to  be  passed  ?  The 
ahnost  universal  rule  in  our  standard  works  is,  that  the,}'  must  be  jjassed 
as  nearly  as  possible  over  the  child's  ears,  without  any  reference  to  the 
jjelvic  diameters.  Hence,  if  the  head  have  not  made  its  turn,  but  is 
lying  in  one  oblique  diameter,  the  blades  would  require  to  be  passed  in 


Fig.  163. 


Position  of  Patient  for  Forceps  Delivery,  and  Mode  of  Introducing  Lower  Blade. 

the  opposite  oblique  diameter ;  in  short,  the  position  of  the  forceps,  as 
regards  the  pelvis,  must  vary  according  to  the  position  of  the  head. 
Some  have  even  laid  down  the  rule  that  the  forceps  is  contraindicated 
unless  an  ear  can  be  felt — a  rule  that  would  very  seriously  limit  its 
application,  as  in  many  cases  in  which  it  is  urgently  required  it  is  a 
matter  of  great  difficulty,  and  even  impossibility,  to  feel  the  ear  at  all. 
It  is  admitted  that  in  the  high  forceps  o]3eration  the  blades  must  be 
introduced  in  the  transverse  diameter  of  the  pelvis,  without  relation  to 
the  position  ofthe  head.  On  the  Continent  it  is  generally  recommended 
that  this  rule  should  be  applied  to  all  cases  of  forceps  delivery  alike, 
whether  the  head  be  high  or  low ;  and  I  have  now  for  many  years 
adopted  this  plan,  and  passed  the  blades  in  all  cases,  whatever  be  the 
pojjjtipn  of  the  head,  in  the  transverse  diameter  of  the  pelvis,  witliout 
any  attempt  to  pass  them  over  the  bi-parietal  diameter  of  the  child's 
head.  Dr.  Barnes  points  out  with  great  force  that,  do  ^hat  we  will  and 
attempt  as  we  may  to  pass  the  blades  in  relation  to  the  child's  head,  they 
find  their  way  to  the  sides  of  the  pelvis,  and  that  the  marks  of  the  fenes- 
tra on  the  head  always  show  that  it  has  been  grasped  by  the  broM'  and 
side  ofthe  occiput.  Ofthe  perfect  correctness  of  this  observation  I  have 
no  doubt ;  hence  it  is  a  needless  element  of  complexity  to  endeavor  to 
vary  the  position  of  the  blades  in  each  case,  and  one  ^^'hich  only  confuses 
the  inexperienced  practitioner  and  renders  more  difficult  an  operation 
which  should  be  simplified  as  much  as  possible.  While,  therefore,  it 
is  of  importance  that  the  precise  position  of  the  head  should  be  ascer- 


THE  FORCEPS. 


481 


tained  in  order  that  we  may  have  an  intelligent  notion  of  its  progress, 
I  do  not  think  that  it  is  essential  as  a  guide  to  the  introduction  of  the 
forceps. 

3Iethod  of  Introducing  the  Lower  Blade. — As  a  rule,  the  lower  blade, 
lightly  grasped  between  the  tips  of  the  index  and  middle  fingers  and 
thumb,  should  be  introduced  first.  Poised  in  this  way,  we  have  perfect 
command  over  it,  and  can  appreciate  in  a  moment  any  obstacle  to  its 
passage.  Two  or  more  fingers  of  the  left  hand  are  introduced  into  the 
vagina  and  by  the  side  of  the  head  as  a  guide.  The  greatest  care  must 
be  taken,  if  the  cervix  be  within  reach,  that  they  are  passed  within  it,  so 
as  to  avoid  the  possibility  of  injury. 

Necessity  of  Gentleness  in  Passing  the  Instrument. — The  handle  of  the 
instrument  has  to  be  elevated,  and  its  point  slid  gently  along  the  palmar 
surface  of  the  guiding  fingers  until  it  touches  the  head  (Fig.  163),  At 
first  the  blade  should  be  inserted  in  the  axis  of  the  outlet,  but  as  it  pro- 
gresses the  handle  must  be  depressed  and  carried  backward.  As  it  is 
pushed  onward  it  is  made  to  progress  by  a  slight  side-to-sicle  motion, 
and  it  is  of  the  utmost  importance  to  bear  in  mind  that  the  greatest  gen- 
tleness must  always  be  used.  IJLany  obstruction  be  felt,  we  are  bound 
to  withdraw  the  instrument  partially  or  entirely,  and  attempt  to  manoeu- 
vre, not  force,  the  point  past  it.  As  the  blade  is  guided  on  in  this  way 
it  is  made  to  pass  over  the  convexity  of  the  head,  the  point  being  always 
kept  slightly  in  contact  with  it,  until  it  finally  gains  its  proper  position. 
When  fully  inserted  the  handle  is  drawn  back  toward  the  perineum  and 

Fig.  164. 


Introduction  of  the  Upper  Blade. 

giyen_in  charge  to  an  assistant.  TJie  insertion  must  be  carried  on  only 
in  the  intervals  between  the  pains^andTJcsistcd  from  during  their  occur- 
rence ;  otherwise  thereTvould  be  a  scTioiis_rislL.of  injurino-  the  soirpal-ts 
of  tl)(!  niotlicr. 

Introduction  of  the  Upper  Blade. — The  second  blade  is  passed  directly 

31 


482 


OBSTETRIC  OPERATIONS. 


opposite  to  the  first,  and  is  generally  somewhat  more  difficult  to  intro- 
cluce  in  consequence  of  the  space  occupied  by  the  latter.  It  is  passed 
along  two  fingers  directly  opposite  the  first  blade,  and  with  exactly  the 
same  precautions  as  to  direction  and  introduction,  exce])tjtliat  at  first  its 
handle  has  to  be  depressed  instead  ofjelevated  (Fig.  164). 

TAM-king  of  the  Handles. — The  handle  which  Avas  in  charge  of  the 
assistant  is  now  laid  hold  of  by  the  operator,  and  the  two  handles  are 
dra^^'n  together.  If  the  blades  have  been  properly  introduced,  there 
should  be  no  difficulty  in  lockiiig ;  but  should  we  be  unable  to  join 
them  easily,  we  must  withdraw  one  or  other,  either  partially  or  entn^ely, 
and  reintroduce  it  Avitli  the  same  precautions  as  before.  AA'e  must  also 
assure~ourselves  that  no  hairs  nor  any  of  the  mat,ernal_structures  are 
caiight~iii  the_lock. 

Jlethod  of  Inaction. — When  once  the  blades  are  locked  we  may  com- 
mence our  effi3rts  at  traction.     To  do  this  we  lay  hold  of  the  handles 

Fig.  165. 


Forceps  in  Position  :  Traction  in  the  Axis  of  the  Brim,  Downward  and  Backward. 

with  the  right  hand,  using  only  sufficient  compression  to  give  a  firm 
grasp  of  the  head  and  to  kee])  the  blades  from  sliiJjiing.  The  left  hand 
may  be  advantageously  used  in  assisting  and  supporting  the  right  during 
our  effi)rts  at  extraction,  and  at  a  late  stage  of  the  operation  may  be  em- 
ployed in  relaxing  the  perineum  when  stretched  by  the  head  of  the  child. 
Traction  must  always  be  made  in  reference  to  the  ])elvic  axes,  being  at 
firsL backwarcLtowaixL  the  perineum  (Fig.  165)  in  the  direction  of  the 
axis  of  thebrim,  and  as  the  head  descends  and  the  vertex  protrudes 
through  the  vulva  it  must  be  changed_to jtha^  of  the  outlet  (Fig.  166). 
If  the  Jijis^raction  Jorceps  is  used,  it  is  to  be  borne  in  mind_that  trac- 
tion is  to  be  made  by  the  traction-handle  Ojily,  the  handles  of  the  instru- 
ment itself  being  left  untoiiched  a fter  they  are  locked  and  the  traction- 


THE  FORCEPS. 


483 


rods  are  united.  By  keeping  these  latter  parallel  to  the  handles  of  the 
forceps  traction  can  always  be  made  in  the  proper  direction.  We  must 
extract  Imly^Huring:  the~pains7and  if  these  should  be  absent  we  must 
imitate  them  by  acting  at  intervals.  This  is  a  point  which  deserves 
special  attention,  for  there  is  no  more  common  error  than  undue  hurry 
in  delivery. 

The  only  valid  objection  I  know  of  against  a  more  frequent  resort  to 
the  forceps  in  lingering  labor  is  that  the  sudden  emptying  of  thejiterus 
in  the  absence  of  pains  may  predispose  to  hemorrhage ;  but  it  cannot  be 
denied  that  it  is  one  of  some  weight.  However,  if  due  care  be  taken  to 
operate  slowly,  and  to  allow  several  minutes_J:Q  elapse  betweeneach 
tractive  effort,  while  at  the  same  time  uterine  contractions  be^sthnulated 
by  pressure  and  support,  this  need  not  be  considered  a  contraindication. 
Besides  direct  traction  we  may  impart  to  jhejnstrument  a  ^ntlejyaying 
motion  from  handle  to  handle,  which  brings  into  operation  its  power  as 
a  lever,  but  this  must  be  done  only  to  a  very  slight  extent,  and  must 
always  be  subservient  to  direct  traction. 

Descent  of  the  Head. — Proceeding  tlius  in  a  slow  and  cautious  manner, 
carefully  regulating  the  force  employed  according  to  the  exigencies  of 

Fig.  166. 


Last  Stage  of  E.\traction.    The  Handles  of  the  Forceps  are  beinf?  Gradually  turned 
Upward  toward  the  Mother's  Abdomen. 

the  case,  we  shall  perceive  that  tlu,"  licad  begins  to  descend  ;  and  its  prog- 
ress  should  Ik;  determined  from  time  to  time  by_  t_he_fingers  of  the  un- 
employed hand. 

T/ir  notation  from  the  Ob/ique  Diameter. — AV^hen  the  head  lies  in  the 
oblique  diameter,  as  it  descends,  in  conse(pience  of  its  perfect  :i(la])tation 


484  OBSTETRIC  OPERATIONS. 

to  the  pelvic  cavity,  it  will  turn  into  the  antero-posterior  diameter  with- 
outjinj^ffort  on  the4)art  of  the  operator,  provided  only  that  the  trac- 
tionjje^ufficientlj  slow  and  gradual.  As  the  head  is  about  to  emerge 
i^jsjiecessary  to  raise  the  handles  tow^ard  the  mother's  abdomen.  ISIore 
than  usual  care  isj;ec[iiired  to  prevent  laceration  of  the  jjerineuiii,  which 
is  ahvays  much  stretched  (Fig.  166).  If,  as  often  happens,  the  pains 
have  now  increased,  and  the  perineum  be  very  thin  and  tense,  it  may 
even~be  desirableto  removetibe  blades  gently,  and  leave  the  case  to  be 
terminatedTWjheliatural  powers  ;  but  if  due  precautions  are  used  this 
need  not  be  necessary. 

The  peculiarities  of  forceps  delivery  in  occipito-posterior  positions 
have  already  been  discussed  (p.  320),  and  need  not  be  repeated. 

High  Forceps  Operations. — When  the  high  forceps  operation  has  been 
decided  on,  the  passage  of  the  blades  ^yil]  be  found  to  be  much  more 
difficult  from^thejieight  of  the  presentino:_]jart,  the  distance  AAliich  they 
must  pass,  and  in  some  cases  from  the  niobility  of  thejiead  interfering 
witlT_dieiT^x3cuK^^  TEe^general  principles  of  introduction 

and  of  traction  are,  however,  identical.  If  the  o])eration  be  attem])ted 
before  the  head  has  entered  the  ]3elvicbrim,  it  must  be  fixed,  as  much 
as  possibTe71)y^bclominal  pressured  IrTguiding  the  blades  to  the  head 
special  care  must  be  taken  to  avoid  any  injury  of  the  soft  parts,  especially 
if  the  cervix  be  not  completely  out  of  reach.  For  this  purpose  it  may 
even  be  advisable  to  introduce  the  entire  left  hand^  as  a  guide,  so  as  to 
a\wXaiiy^possn3iIity  of  injuring  the  cervix  from  not  passing  the  instru- 
ment under  its  edge. 

Peculiar  Method  of  Introducing  the  Blades. — Some  authors  advise 
that  in  such  cases  the  blade  should  be  introduced  at  first  opposite  the 
sacrum  until  the  point  approaches  its  promontory.  It  is  then  made  to 
sweep  round  the  pelvis,  under  the  protecting  fingers,  till  it  reaches  its 
proper  position  on  the  head.  This  plan  is  advocated  by  Ramsbotham, 
Hall  Davis,  and  other  eminent  practical  accoucheurs,  and  it  is  certainly 
of  service  in  some  cases  of  difficulty,  especially  when,  from  any  reason, 
it  is  not  possible  to  draw^  the  nates  over  the  edge  of  the  bed,  wdien  the 
necessary  depression  of  the  handle  of  the  upper  blade  is  difficult  to  eifect. 
It  involves,  hoAvever,  a  somewhat  complicated  manoeuvre,  and  it  is  sel- 
dom that  the  blades  cannot  be  readily  introduced  in  the  usual  way. 

Necessity  of  Care  in  Locking. — Ii]_locking,  the  slightest  approach  to 
roughness  must  be  carefully  avoiiled,  for  the  extremities  of  the  blades 
arejiow_within  the  cavity  of  the  uterus,  and  serious  injury  might_eagily 
beJjifUcted.  If  difficulty  be  met  with,  rather  than  employ  any  force 
one  of  the  blades  should  be  withdrawn  and  reintroduced  in  a  more  favor- 
able direction.  If  the  blades  have  shanks  of  sufficient  length,  there 
should  be  no  risk  of  including  the  soft  parts  of  the  mother  in  the  lock ; 
W'hich  in  a  badly-constructed  instrument  is  an  accident  not  unlikely  to 
occur. 

3Iethod  of  Traction. — After  junction,  traction  imist  at  first  be  alto- 
gether in  the  axis  of  the  brjni,  and  to  eifect  this  the  handles  must  be 
pressed  Mell  backward  toward  the  peri'neum.  As  the  head  descends  it 
will  probabl)"  take  the  usual  turn  of  itself,  without  effort  on  the  part  of 
the  operator,  and  the  direction  of  the  tractive  force  may  be  gradually 


THE  FORCEPS.  485 

altered  to  that  of  the  axis  of  the  outlet.  If  the  pains  be  strong  and 
reg!;ular  and  there  be  no  indication  forjmmediate  delivery,  we  may  re- 
nipye  the  forceps  atter  tlfe  head  ""lms~descended  upon  the  perineum,  and 
leaYg  the  conclusion  of  the  case  to  nature.  This  course  may  be  especially 
advisable  if  the  perineum  and  soft  parts  be  unusually  rigid,  but  generally 
it  js^better  to  terminate  labor  without  removing  the  instrunient. 

Possible  Dangers  of  Forceps  Delivery. — Before  concluding  this  subject 
reference  may  be  made  to  the  possible  dangers  of  the  operation.  I  would 
here  again  insist  on  the  importance  of  distinguishing  between  the  high 
and  low  forcejDS  operations,  which  have  been  so  unfortunately  and  un- 
fairly confounded.  Reasons  have  already  been  given  for  rejecting  the 
statistics  of  the  risks  attending  forceps  delivery  in  the  latter  class  of 
cases  (p.  347).  A  formidable  catalogue  of  dangers,  both  to  mother  and 
child,  might  easily  be  gathered  from  our  standard  works  on  obstetrics. 
Among  the  former,  the  principal  are  lacerations  of  the  uterus,  vagina, 
and  perineum  ;  rupture  of  varicose  veins,  giving  risejtojthroinbus  ;  p£l- 
vic  abscess,  from  contusion  of  the  soft  parts ;  subsequent  inflammation 
of  the  uterus  or  peritoneum  ;  tearing  asunder  of  the  joints  and  symphyses ; 
and  even  fracture  of  the  pelvic  bones.  A  careful  analysis  of  these,  such 
as  has  been  so  well  made  by  Drs.  Hicks  and  Philips, '^  proves  beyond 
doubt  that  the  application  of  the  instrument  is  not  so  much  concerned  in 
thei  reproduction  as  the  protraction  of  the  laborand  the  neglect  of  the 
prax^titiomT^nTnoOnterfering  sufficiently  soon  to  prevent  the_occurrence 
ofjdie_evil  consequences,  aijerward  attributed  to  the  operation  itself. 
Many  of  these  will  be  found  to  arise  from  the  prolonged  pressure  on  the 
soft  parts  within  the  pelvis,  and  the  subsequent  inflammation  or  slough- 
ing. To  these  causes  may  be  referred  with  propriety  most  cases  of 
vesico-vaginal  fistula  (p.  439),  peritonitis,  and  metritis  following  instru- 
mental labor. 

Some  Depend  on  Ignorance  on  the  Part  of  the  Practitioner. — Lacera- 
tions and  similar  accidents  may,  however,  result  from  an  incautious  use 
of  the  instrument.  Slight  lacerations  of  the  mucous  membrane  of  the 
vagina  are  probably  far  from  uncommon.  But  if  these  cases  were  closely 
examined,  it  would  be  found  that  the  fault  lay  not  in  the  instrument, 
but  in  the  hand  that  used  it.  Either  the  blades  were  introduced  without 
due  regard  to  the  axes  of  the  pelvis,  or  they  were  pushed  forward  with 
force  and  violence,  or  an  instrument  was  employed  unsuitable  to  the 
case  (such  as  a  short  straight  forceps  when  the  head  was  high  in  the, 
pelvis),  or  undue  haste  and  force  in  delivery  were  used.  It  would  be 
manifestly  unfair  to  lay  the  blame  of  such  results  upon  the  forceps, 
whif;h  in  the  hands  of  a  more  judicious  and  experienced  practitioner 
would  have  effected  the  desired  object  with  perfect  safety.  The  instru- 
ni(!nt  is  doubtless  unsaf(i  in  the  hands  of  any  one  who  does  not  under- 
stand its  use,  just  as  the  scalpel  or  amputating-knife  would  be  in  the 
hands  of  a  rash  and  inexperienced  surgeon.  The  lesson  to  be  learnt 
seems  to  l>e,  dearly,  not  that  tlu;  dangers  should  deter  us  from  the  use  of 
the  forceps,  but  that  they  sliould  induce  us  to  study  more  cansfully  the 
cases  in  \vlii<"li  it  is  jipplicabk;  and  tlu!  method  of  using  it  with  safety. 

PoHslhle  Risks  to  the  (J/uhl. — TIk;  (lan<j!;ers  to  the  child  are,  principally, 

'  0/as/.  Trcmx.,  vol.  xiii. 


486  OBSTETRIC  OPERATIONS. 

lacerations  of  the  integuments  of  the  scalp  and  foreligad  ;  cojitusion  of 
the  face ;  }3artial  but  temporary  paralysis  of  the  faceJroaLpressure  of  a 
blade  on  the  facjaLiierve  ;  depression  or  fracture  of  tIie_craniaL  bones  ; 
injury  to  the  brain  from  undue  pressure  of  the  blades.  These_eyils^ are 
of  rare  occurrence,  and,  when  they  do  ha])pen,  generally  result  from 
improper  management  of  the  operation — such  as  undue  compression,  the 
use  of  improper  instruments,  or  excessive  and  ill-directed  efforts  at  trac- 
tion— and  cannot,  therefore,  be  considered  as  in  any  way  contraindicating 
the  use  of  the  instrument.  Many  of  the  more  common  results,  such  as 
slight  abrasions  of  the  scalp  or  paralysis  of  the  face,  are  transitory  in 
t h eir  nature  and  of  no  real  consequence. 

[  The  Forceps  in  America. — Although  the  obstetrical  forceps  was  first 
used  in  England,  other  countries  in  the  march  of  improvement  have 
made  great  changes,  not  only  in  the  original  forms,  but  in  the  manner 
of  use  ;  and  various  shapes,  as  well  as  different  positions  of  the  Avoman 
in  application,  have  become  in  a  measure  national.  With  the  exception 
of  having  adopted  almost  exclusively  the  French  and  German  dorsal 
decubitus  in  making  use  of  the  instrument,  we  have  become  in  a  measure 
eclectic  in  the  selection  of  the  latter ;  medical  schools,  accoucheurs,  and 
local  obstetrical  societies  influencing  students  and  the  junior  members  of 
the  profession  to  adopt  the  French,  German,  English,  or  American  style, 
as  the  case  may  be,  the  forceps  themselves  bearing  the  names  of  the  sev- 
eral inventors  or  compilers ;  for  some  are  a  true  compilation — the  blade 
from  one  contriver ;  fenestral  openings,  another ;  pelvic  curve,  a  third  ; 
width,  a  fourth ;  shanks,  a  fifth ;  method  of  locking,  a  sixth  ;  etc.  etc. 
For  this  reason  the  late  Prof.  Hodge  named  his  forceps  the  eclectic, 
although  in  some  respects  entirely  original,  particularly  in  the  long 
superimposed  shanks — a  great  improvement  for  operating  at  the  superior 
strait  and  avoiding  the  painful  stretching  of  the  posterior  commissure  of 
the  vulva.  Dr.  Hodge  expended  a  great  deal  of  thought  and  money  in 
perfecting  his  forceps,  and  the  various  steps  in  the  process  M^ere  marked 
by  a  new  form,  until,  from  a  heavy,  clumsy  instrument,  he  gradually 
evolved  what  was  at  one  time  regarded  as  a  wonderful  improvement 
upon  the  forceps  of  France  and  England. 

A  contemporary  of  Prof.  Hodge,  the  late  Prof.  David  D.  Davis  of 
London,  was  equally  anxious  to  perfect  the  instrument,  and  turned  his 
attention  especially  to  making  the  blades  light,  open,  and  to  fit  the  sides 
of  the  foetal  head  so  as  to  enable  traction  to  be  made  without  much  pres- 
sure or  leaving  any  mark  on  the  child's  scalp.  There  is  a  principle  of 
mechanics  involved  in  his  instrument  which  he  studied  to  perfect  by 
moulding  the  blades  so  as  to  obtain  considerable  coaptating  surface,  and 
thus  by  increase  of  friction  to  avoid  undue  and  dangerous  i)rcssure. 
The  Davis  blade  soon  began  to  effect  changes  in  the  form  of  American 
forceps,  and  by  the  addition  of  long  handles  and  some  alterations  of 
shape,  weight,  and  curve  became  a  leading  feature  in  those  bearing  the 
names  of  William  Harris,  Prof.  Wallace  of  the  Jefferson  Medical  Col- 
lege, Dr.  Bethel,  and  Albert  H.  Smith,  all  of  this  city.  The  short  Davis 
instrument  was  a  great  favorite  with  the  late  Prof.  Meigs  and  Dr.  Wil- 
liam Harris,  both  largely  engaged  in  obstetrical  practice  as  well  as 
teaching ;  and  many  a  delicate  woman  ^^•itll  wasting  forces  was  aided  in 


THE  FORCEPS.  487 

her  delivery  at  their  hands,  and  was  surprised  to  find  no  mark  on  the 
baby's  head,  and  that  her  own  sufferings  could  be  so  gently  and  safely 
relieved. 

Although  such  was  the  estimation  of  the  Davis  blade,  and  still  is  in 
many  parts  of  our  country,  it  does  not  appear  to  have  retained  its  popu- 
larity or  been  adopted,  as  its  mechanical  perfection  would  lead  one  who 
appreciates  it  to  suppose  it  would  have  been.  In  Great  Britain  the 
favorite  forms  now  in  use  are  but  a  very  slight  improvement  upon  the 
forceps  of  a  hundred  years  ago  except  in  finish  and  material,  the  open 
fenestrse  and  bevelled  blades  of  Davis  being  declined  in  favor  of  the 
looped  fenestrse  and  flat-edged  blades  in  use  when  he  made  his  experi- 
ments and  changes.  This  appears  to  have  grown  out  of  a  practice  which 
has  been  largely  adopted  in  Germany,  Great  Britain,  and  many  parts  of 
the  United  States  in  applying  the  forceps  to  the  foetal  head,  the  blades 
being  introduced  at  the  sides  of  the  pelvis,  without  much  reference  to  the 
position  which  the  head  occupies.  As  compression  is  objected  to,  the 
blades  are  made  long  and  widely  separated  (3^  to  3|-  inches),  and  the 
handles  short,  so  as  not  to  allow  of  much  leverage.  As  the  blades  do  not 
fit  the  head,  the  mechanism  of  labor  as  taught  by  Hodge  has  been  much 
simplified,  as  it  is  not  necessary  to  learn  all  the  oblique  fittings  of  the 
fenestrse  over  the  parietal  protuberances  or  ears.  Dr.  Meigs  used  to  tell  the 
students  that  the  forceps  was  the  "  child's  instrument,'^  and  should  be  used 
as  a  tractor ;  and  it  was  as  a  well-applied  mechanical  tractor  that  he  advo- 
cated the  use  of  the  Davis  blades  against  those  of  Siebold,  Levret,  Bau- 
delocque,  and  Haighton,  employed  generally  in  our  country  forty  years 
ago.  His  language  is  not  very  complimentary  to  what  he  denominates 
by  distinction  ^Hhe  mother's  instrument,''  the  form  being  better  adapted 
for  saving  the  woman  than  the  foetus.^ 

At  the  present  day  we  have  two  general  orders  of  forceps  in  use  in 
the  United  States,  under  each  of  which  may  be  placed  a  vast  number 
of  special  varieties  which  are  simply  changes  upon  one  or  the  other  gen- 
eral type  according  to  the  fancy  of  the  inventor.  At  the  head  of  one 
type  may  be  placed  the  long  forceps  of  Prof.  Hodge,  designed  to  be 
adapted  to  the  sides  of  the  child's  head  in  all  possible  cases  ;  and  of  the 
other,  those  of  Prof.  Simpson  of  Edinburgh  or  their  modification  by 
Profs.  Elliot  and  Bedford  of  New  York,  intended  to  be  used  as  trac- 
tors, and  applied  in  reference  to  the  sides  of  the  mother's  pelvis,  rather 
than  to  those  of  the  infant's  head.    -J^^X cxtv i> s.  j^tb;^/- 

Taking  the  long  forceps  of  Levret  and  Baudelocque  as  improved  and 
modified  by  Hodge,  with  the  blades  of  Prof.  Davis  as  a  substitute,  and 
handles  of  less  curve  than  those  of  Hodge,  and  we  have  the  long  for- 
ceps of  Prof.  Ellerslie  Wallace,  late  of  the  Jefferson  Medical  College,  the 
most  fre(]ueiit  choice  of  those  who  jiurchase  forcejis  of  the  manufacturers 
in  Phi]ade]])lila.  N(!xt  in  order  are  the  instruments  of  Hodge,  Davis, 
and  Simpson,  Elliot,  Bedford,  and  a  few  others — in  all  about  a  dozen 
forms  that  vary  in  j)0[)ularity.  The  improvement  of  the  late  Prof.  Elliot 
upon  the  instrument  of  Sim])son  consists  in  narrowing  and  lengthening 
the  shanks,  widening  somewhat  the  fi^nestra),  elongating  the  blades,  giv- 
ing greater  security  against  sli])|)ing  in  tin;  handles,  and  gauging  the  dis- 

['   ()hMrlrii'>^,  p.  r,4().] 


488 


OBSTETRIC  OPERATIONS. 


tance  between  the  blades  by  a  milled-head  screw-stop  in  the  end  of  the 
handles :  the  shanks  and  blades  are  an  exact  counterpart  of  the  Miller 
forceps  of  England,  which  appeared  about  the  same  time  (1858). 

The  Hodge  forceps  was  based  in  its  contrivance  upon  the  folloM-ing 
points  :  1 .  The  instrument  should  be  shaped  to  the  contour  of  the  fretal 
head,  and  have  sufficient  play  to  allow  of  compression  where  the  pelvis 
is  too  narrow  for  the  head  to  pass  in  its  normal  condition.  2.  The  blades 
should  be  so  arranged  in  reference  to  the  shanks  and  handles  as  to  enable 
them  to  seize  the  head  of  the  foetus  in  its  bi-parietal  diameter  at  the 
superior  strait,  and  be  drawn  upon  in  the  direction  of  the  curve  of  the 


Fiu. 167. 


Fig.  168. 


Fig.  169. 


Hodge  Foroeps. 


Wallace  Forceps. 


Davis  Forceps. 


pelvic  canal  until  the  delivery  is  complete.  3.  The  long  forceps  ought 
to  be  competent  to  act  either' at  the  superior  strait  of  die  pelvis,  in  its 
cavity  or  at  its  outlet,  so  as  to  avoid  a  mukiplicity  of  instruments  and 
their  attendant  expense.  And,  4.  The  instrument  should  not  cut  the 
scalp  of  the  child  if  properly  adjusted,  or  injure  the  soft  parts  of  the 
mother. 

It  would  be  folly  to  claim  that  all  this  could  or  has  been  accom- 
plished, as  there  must  necessarily  be  exceptional  cases  in  all  the  points 
given  ;  hence  the  contrivance  of  ithe  forceps  of  Tarnier  and  Cleemann  for 


THE  FORCEPS.  489 

certain  presentations  above  the  superior  strait,  and  the  long  and  short  con- 
vertible instrimients  of  a  few  inventors.  There  are  many  cases  of  labor 
in  the  higher  walks  of  life  where,  although  there  is  no  obstruction,  still 
the  women  require  manual  or  instrumental  assistance,  as  they  cannot 
deliver  themselves  for  want  of  sufficient  contractile  muscular  force.  Such 
women  require  that  the  forceps  used  should  be  easily  introduced — should 
act  simply  as  tractors,  control  the  movement  of  the  foetal  head  by  being 
well  fitted  to  its  shape,  and  leave  no  eifect  upon  the  scalp  or  vulva. 
Although  these  requisites  may  be  filled  by  the  Hodge  instrument,  it  is 
this  class  of  cases  that  has  demanded  a  lighter  and  more  roomy  pair  of 
forceps,  such  as  that  devised  by  Davis. 

As  the  teaching  of  the  Jefferson  Medical  College  under  Dr.  Meigs 
favored,  as  we  have  stated,  the  forceps  of  Davis,  so  nis  successor.  Prof. 
Wallace,  in  carrying  out  in  a  measure  the  same  views,  combined  the 
blades  of  the  Davis  pattern  with  the  long  handles  of  Hodge  in  cout 
triving  what  is  known  as  the  "  Wallace  forceps,''  now  so  much  in  use 
by  the  large  number  of  graduates  of  this  school.  As  compared  with 
the  Hodge  instrument,  it  is  1  inch  shorter  (15  inches  against  16);  the 
blades  are  of  the  same  length  (6  inches) ;  the  fenestrse  are  more  open ; 
the  shanks  are  only  half  the  length,  giving  a  much  greater  compressing 
power ;  and  the  handles  are  of  the  same  measurement  from  pivot  to 
hooks.  Both  have  the  Siebold  lock,  over  which  we  believe  the  broad- 
topped  button  and  notch  to  possess  some  advantages ;  and  the  Wallace 
is  somewhat  heavier  than  the  Hodge,  which  should  weigh  17  ounces. 

The  short  Davis  instrument  made  for  Prof.  Meigs  under  direction  of 
the  inventor  weighed  10|-  ounces  and  measured  12  inches  in  length; 
fenestrse,  5  inches  long,  2  inches  wide  ;  blades  separated  2|^  inches ; 
handles,  4^  inches  to  lock,  which  was  of  the  Smellie  or  English  pat- 
tern. A  recently-purchased  pair  in  possession  of  the  editor  is  13^ 
inches  long,  with  5-inch  handles,  a  button  lock,  2-inch  close-set  shanks, 
and  6^-inch  blades.  I  believe  the  changes  are  decided  improvements, 
especially  the  lock  and  elongated  handles.  It  has  answered  admirably 
in  adynamic  cases,  requiring  only  a  few  pounds  of  tractile  assistance. 
The  Davis  blades  have  been  added  to  long  handles,  and  the  whole 
made  of  steel  and  marvellously  light,  at  the  special  request  of  a  few 
accoucheurs,  who  wished  them  to  aid  in  some  cases  of  arrest  at  the 
perineum. 

The  late  Prof.  George  T.  Elliot  of  New  York,  who  received  much 
of  his  practical  obstetrical  training  in  the  Dublin  Lying-in  Hospital, 
imljihcd  the  teachings  of  the  English  school,  and  became  impressed  with 
the  value  of  the  system  as  taught  by  Simpson,  upon  the  principle  of 
whose  forceps,  modelled  somewhat  after  that  of  the  late  Prof.  Gunning 
S.  Bedfi>rd  of  New  York,  he  in  1858  presented  to  the  medical  profes- 
sion the  instrument  that  bears  his  name.  The  forceps  of  Prof.  Bedford 
lias  a  ti-action-ring  on  each  side  where  the  Elliot  has  a  cornu,  has  a  but- 
ton joint,  instead  of  a  Srncllic!,  has  no  screw-stop,  and  has  diverging 
inst(!ad  of  siijKirinijwsed  shanks.  These  ])()ints  have  generally  been  con- 
sid(;red  as  im[)rovements,  and  hence  the  Elliot  has  tak(!n  ])recedcnce  in 
Iarg(;  measure  over  the  l^edford  instrument  in  New  York,  the  two  being 
the  leading  forceps  in  demand.     The  instrument  of  White  of  Buffalo  is 


41)(l 


OBSTETRIC  OPERATIONS. 


perhaps  next,  and  then  Hodge's.  But  few  of  Prof.  Wallace's  forceps, 
long  the  leading  instrument  in  Philadelphia  sales,  are  ordered.  The 
White  is  a  long  forceps,  a  compound  of  the  Elliot  blade,  long  super- 
imposed shanks  of  Hodge,  Siebold  lock,  and  short  corrugated  steel 
handles  bowed  out  like  dental  forceps  and  ending  in  thin  blunt  hooks. 
The  Sawyer  and  Simpson  short  forceps  are  said  to  be  about  equally 
in  demand  in  New  York.  The  former  is  almost  unknown  in  Phila- 
delphia, and  but  comparatiyely 
Fig.  170.         few    of    the    Simpson   are   asked  Fig.  171. 

for,  although  the  system  of  their 

application  has  several  advocates 

in  this  city. 

The  Sawyer  Forceps. — This  is 

the  lightest  of  all  the  varieties  of 

the  short  forceps,  weighing  but  5 

ounces,  and  measuring  Of  inches 

in    length ;    the   handle   being    3 

inches,   shank   1^,  and   chord  of 


blade-curve  5^. 


The  blades  ai^e  1^ 

7 


Sawyer  Forceps. 


inches  wide,  with  oval  fenestrse 

inch  wide,  and  separated  2|^  inches 

at  their  widest  part  and  f  inch 

at  the  tips.     This  instrument  was 

invented  eight  years  ago  by  Prof. 

Edw.   Warren   Sawyer   of  Rush 

Medical  College,  Chicago,  and  has 

been  highly  commended  by  Prof. 

Byford  and  others.     The  forceps 

has  the  blades  of  Davis,  sujjerim- 

posed  shanks  of  Hodge,  and  lock 

of  Smellie,  with  hard-rubber  plates 

moulded    hot    upon    the  handles. 

The  several  parts  have  been  some- 
what modified,  the  object  being  to  secure  a  tractor  for 

cases  of  deficient  expulsive  force  where  the  foetal  head 

is  low  in  the  pelvis. 

Professor  Sawyer  says :  "  In  the  labors  to  which  my 
forceps  is  applicable  it  is  not  necessary  for  the  operator's  body  to  be  in 
line  with  the  pelvic  axis.  My  mode  of  procedure  is  the  following : 
The  woman  is  placed  upon  her  back  and  drawn  to  the  edge  of  the  bed ; 
the  outside  leg  is  now  flexed ;  beneath  this  flexed  extremity  and  the 
bed-covering  I  apply  the  forceps — often  using  but  one  hand  in  the 
operation.  When  the  instrument  is  locked,  I  grasp  the  handle  in  such 
a  manner  that  the  palm  of  the  hand  looks  upward ;  one  hook  then 
rests  naturally  upon  the  extensor  surface  of  the  first  phalanx  of  the 
index  finger,  while  the  other  hook  rests  upon  a  corresponding  part  of 
the  thumb.  When  thus  adjusted,  I  lift  the  head  from  the  pelvic  outlet, 
at  the  same  time  invoking  the  pendulum  movement  if  desired.  At  this 
moment  the  advantage  of  tlie  hooked  handle  is  very  apparent  to  the 
operator."    .    .    .    .   "  All    practitioners    must    have  often    felt,    during 


Elliot  Forceps. 


THE  FORCEPS. 


491 


the  last  moments  of  labor,  when  the  uterus  and  the  mother  seemed  fa- 
tigued, the  need  of  a  little  help  to  the  expansive  powers.  The  ordinary 
instruments  are  too  formidable  to  be  used  at  the  last  moment,  and  it  is 
then  that  this  little  forceps  is  useful." 

I  have  given  the  names  and  characters  of  the  various  forceps  most  in 
use  in  New  York  and  Philadelphia,  and  by  the  large  number  of  gradu- 
ates of  their  respective  schools,  as  shown  by  their  preferences  in  select- 
ing instruments  of  the  leading  makers  of  the  two  cities.  The  mechan- 
ism of  instrumental  delivery  is  much  simplified  by  applying  the  forceps 
to  whatever  parts  of  the  foetal  head  may  be  opposite  the  sides  of  the 
pelvis ;  but  it  is  very  questionable  whether  it  is  the  scientific  method 
or  the  safer  for  the  child.  With  one  blade  over  the  side  of  the  occiput, 
and  the  other  over  that  of  the  forehead — which  is  the  manner  of  seizure 
in  oblique  positions  of  the  \'ertex — we  certainly  have  not  a  very  secure 

Fig.  172. 


ApplifatifJii  of  the  Forceps  at  the  liilci-ior  Strait. 

hold  and  run  some  risk  of  injury  to  the  fretus.  The  advocates  of  this 
system  claim  that  they  use  no  compression,  only  a  sim]ile  traction  ; 
which  may  V)e  true  in  one  sense,  but  amounts  to  the  same  in  effect,  else 
how  fould  Di-.  Elliot,  by  ti'action  \vith  great  force,  straighten  out  one 


492  OBSTETRIC  OPERATIONS. 

of  the  blades  of  his  Simpson  forceps,  as  related  in  the  New  York  Journ. 
of  Medk-'me  for  September,  1858,  p.  161,  in  the  paper  which  he  pre- 
sented describing  his  new  forceps  and  a  nnmber  of  cases  in  which  he 
had  tested  them?  It  makes  but  little  difference  whether  we  compress 
the  head  before  we  begin  to  pull,  or  pull  so  as  to  wedge  the  head 
between  the  blades,  and  thus  compress  it,  except  as  to  the  difference  of 
tit  in  the  two  instances ;  the  adjusted  and  even  pressure  being  the  less 
likely  to  injure  the  foetus.  I  have  always  believed  that  the  forceps 
should  fit  the  head,  and  that  the  student  should  be  taught  how  to 
accomplish  it  correctly  in  the  various  positions  of  the  foetus.  If  the 
student  has  a  mechanical  turn  of  mind,  a  delicate  sense  of  touch,  and  a 
clear  head,  he  will  soon  learn ;  if  he  is  not  a  mechanic,  he  will  be  forced 
to  adopt  a  more  simple  method  of  delivery.  In  a  large  city  there  are 
but  feM^  first-class  obstetrical  manipulators  as  a  general  rule,  and  they 
are  usually  well  known  as  such,  for  the  reason  that  but  few  have  all  the 
requisites  to  enable  them  to  achieve  notoriety ;  and  yet  there  are  hun- 
dreds who  can  deliver  a  woman  with  forceps  moderately  well.  To  one 
the  mechanism  of  Hodge  is  a  simple  matter  and  soon  mastered ;  to 
another  it  is  a  useless  complication,  and  he  prefers  the  more  simple  sys- 
tem. Hence  the  great  differences  between  obstetricians  as  to  the  best 
instrument  and  the  best  method  of  application.  Some  of  the  vast  array 
of  patterns  have  decided  merit  and  display  much  mechanical  skill,  while 
others  serve  only  to  amuse  the  educated  examiner.  One  obstetrician, 
after  the  manner  of  Elliot,  uses  a  variety  of  forceps  one  after  another  in 
the  same  case,  and  pulls  with  great  force,  while  another  confines  his 
work  almost  to  one  instrument,  adjusts  it  easily,  pulls  moderately,  and 
seldom  fails.  There  are  no  doubt  exceptions,  but  certainly  the  most 
delicate  manipulators  we  have  seen,  believed  in  and  practised  the  teach- 
ings of  Hodge  and  Meigs.  There  may  be  cases  where  it  might  be  well 
to  practise  the  method  of  Simpson,  as  is  done  occasionally  by  some  of 
our  leading  practitioners,  but  we  cannot  see  why  his  plan  of  delivery 
should  be  exclusively  used  on  any  mode  of  scientific  reasoning. 

I  present  a  series  of  plates  in  illustration  of  the  American  method  of 
delivery  with  the  forceps,  the  position,  as  will  be  seen,  being  that  of 
France  and  Germany — on  the  back.  AVhen  it  is  decided  to  use  the  for- 
ceps, in  almost  all  cases  in  the  United  States  the  patient  is  brought  to 
the  edge  of  the  bed  on  her  back,  with  her  nates  close  to  the  edge,  her 
feet  on  two  chairs,  and  her  knees  widely  separated,  as  in  the  plate  above. 
The  patient  is  covered  with  a  sheet,  or  heavier  covering  if  in  winter, 
and  there  is  no  necessity  of  exposure,  as  the  whole  manipulation  may 
be  done  by  the  sense  of  touch.  The  position  is  by  far  the  most  conveni- 
ent for  the  obstetrician,  and  enables  him  much  more  easily  to  keep  in 
his  mind  all  the  anatomical  relations  of  the  foetus  and  pelvis  than  when 
in  the  English  decubitus.  AVe  study  the  anatomy  with  the  subject  on 
the  back,  and  the  mechanism  of  labor  in  front  of  the  pelvis  or  manikin  ; 
then  why  complicate  matters  by  a  change  of  position,  ^\hicli,  to  say  the 
least,  is  a  very  awkward  one,  particularly  in  introducing  the  long  for- 
ceps, setting  it  according  to  the  instructions  of  Hodge,  and  carrying  it 
forward  between  the  thighs  as  the  head  emerges  ?  I  have  used  the  short 
forceps  in  an  exhausted  case  with  the  woman  on  her  side,  but  found  it 


THE  FORCEPS. 


493 


much  less  convenient  for  the  various  movements,  although  I  soon  deliv- 
ered the  foetus.  As  to  the  question  of  exposure,  there  is  less  in  apj)ear- 
anee  than,  in  fact,  in  the  English  position,  in  many  cases.  If  the  patient 
and  nurse  are  fastidious  and  careful  during  the  use  of  the  forceps,  the 
accoucheur  can  manage  without  his  eyes  in  a  large  proportion  of  cases ; 
but  the  fault  of  exposure  lies  more  frequently  in  the  temporary  reckless 
indifference  begotten  of  pain  and  suffering  in  the  woman,  than  in  any 
act  of  the  accoucheur  if  inclined  to  spare  the  feelings  of  his  patient  as 
much  as  possible. 

The  long  forceps,  with  its  pelvic  curve,  was  specially  designed  for  use 
at  the  superior  strait  of  the  pelvis,  the  curve  of  the  blades,  as  in  the 

Fig.  173.  "     . 


Application  of  the  Forceps  witli  tlie  IIcjuI  >\X.  the  S\iperior  Strait,  the  Left  Blade  held  in  Place  by 

an  Assistant. 

Davis  iiLStruincnt  modiiied  hy  Walhice,  being  intended  to  correspond 
with  the  direction  of  the  occipito-mental  diameter  of  the  foetal  head. 
The  long  superimposed  shanks  ai'  several   varieties  of  tlie  long  forceps 


494 


OBSTETRIC  OPERATIONS. 


will  liere  be  found  valuable,  as  the  lock  is  not  introduced  or  the  posterior 
commissure  of  the  vulva  widely  stretched.  If  the  head  is  entirely  above 
the  strait,  the  line  of  the  blades  must  be  changed  correspondingly,  in 
order  to  apply  them  properly  and  keep  the  line  of  traction  within  the 


Direction  of  the  Forceps  as  the  Head  is  being  Delivered . 


coccyx ;  and  even  then,  to  draw  in  the  proper  direction,  the  left  hand 
must  act  at  first  in  a  backward  direction  from  the  lock,  while  the  right 
brings  the  handles  downward,  for^\ard,  and  then  upA\'ard ;  both  hands 
describing  a  curve,  but  that  of  the  right  being  much  the  greater.  The 
jDCculiar  forceps  of  Tarnier  or  of  Cleemann,  being  designed  to  meet  this 
form  of  exigency,  may  be  brought  into  requisition.  These  both  have 
the  blades  of  Davis. 

In  latter  years  it  has  become  much  more  common  than  formerly  to 
introduce  the  forceps  into  the  uterus  before  it  is  fully  dilated,  in  conse- 
quence of  the  success  claimed  for  the  plan  as  carried  out  in  the  Dublin 
Lying-in  Hospital.  As  this  should  never  be  done  where  the  os  is  not 
readily  dilatable,  and  requires  much  skill  in  execution,  it  is  not  safe  to 
recommend  its  general  adoption  in  cases  of  delay  in  private  practice. 

The  forceps  should  not  be  introduced  with  any  force,  but  the  left  blade 
should  -be  slid  in  gently,  and  with  a  spiral  motion,  and  then  the  right, 
care  being  taken  that  they  should  also  lock  without  force,  which  they 
will  do  if  jjroperly  adjusted.     Traction  is  to  be  exerted  slowly  and  dur- 


THE   VECTTS.—THE  FILLET.  495 

ing  a  pain,  the  whole  movement  being  made  to  correspond  with  the 
natural  as  closely  as  possible. 

As  the  foetal  head  comes  under  the  arch  of  the  pubes  the  handles  of 
the  forceps  must  rise  more  and  more  from  the  bed,  until  at  last  they  are 
over  the  abdomen  as  the  head  emerges  from  the  perineum.  This  last 
movement  of  instrumental  delivery  should  be  a  very  slow  one,  for  fear 
of  rupture.  It  has  been  proposed  to  remove  the  blades  before  delivery 
is  complete ;  but  there  is  no  occasion  for  this  if  the  forceps  is  applied  to 
the  sides  of  the  head  over  the  parietal  protuberances,  as,  where  these 
protrude  and  the  blades  are  flat  and  thin,  there  is  very  little  additional 
space  required.  With  such  instruments  as  the  old  Levret,  Baudelocque, 
and  Rohrer  forceps,  with  looped  or  kite-shaped  fenestrse  and  thick  edges, 
this  was  a  much  more  imperative  direction  than  with  the  better  instru- 
ments of  the  present  day.  With  a  Sawyer  forceps  the  perineum  ought 
to  be  safer  and  under  better  control  than  without.  When  the  perineum 
is  thought  to  be  in  danger,  the  process  of  distension  should  be  retarded 
through  two  or  three  pains,  or  even  more  if  required,  instead  of  draw- 
ing the  head  through  at  once. 

After  the  head  is  delivered,  if  the  cord  is  not  around  the  neck,  and 
therefore  in  danger  from  pressure,  the  body  should  be  allowed  to  remain 
until  the  uterus  has  well  contracted  upon  it,  for  fear  of  hemorrhage  after 
delivery  from  uterine  inertia. — Ed.] 


CHAPTER   lY. 

THE  VECTIS.— THE  FILLET. 

The  Vectis. — In  connection  ^vith  the  subject  of  instrumental  delivery 
it  is  essential  to  say  something  of  the  use  of  the  vectis,  on  account  of 
the  value  which  was  formerly  ascribed  to  it,  which  was  at  one  time  so 
great  in  this  country  that  it  became  the  favorite  instrument  in  the 
metropolis ;  Denman  saying  of  it  that  even  those  who  employed  the 
forceps  were  "  very  willing  to  admit  the  equal,  if  not  superior,  utility 
and  convenience  of  the  vectis."  Even  at  the  present  day  there  are  prac- 
titioners of  no  small  experience  wlio  believe  it  to  be  of  occasional  great 
utility,  and  use  it  in  preference  to  the  forceps  in  cases  in  which  slight 
assistance  only  is  required.  In  sjiite,  however,  of  occasional  attenqjts 
to  recommend  its  use,  the  instrument  has  fallen  into  disfavor,  and  may 
be  said  to  be  practically  obsolete. 

Nature  of  the  Tastrumetif. — Tlie  vectis,  in  its  most  a])proved  form, 
consists  of  a  single  blade,  not  unlike  that  of  a  short  straight  forceps, 
attached  to  a  wo(jd(.'n  handle.  A  variety  of  modifications  exists  in  its 
shape  and  size.  The  handle  has  been  occasionally  manufactured,  for  the 
convenience  of  carriage,  with  a  hinge  close  to  the  commencement  of  the 


496 


OBSTETRIC  OPERATIONS. 


Fig.  175. 


blade  (Fig.  175),  or  with  a  screw  at  the  point  where  the  handle  and 
blade  join.  The  power  of  the  instrument  and  the  facility  of  introduc- 
tion depend  very  much  on  the  amoimt  of  curvature  of  the  blade.  If 
this  be  decided,  a  firmer  hold  of  the  head  is  taken  and 
greater  tractive  force  is  obtained,  but  the  difficulty  of  intro- 
duction is  increased. 

The  Veetis  is  Used  either  as  a  Lever  or  a  Tractor. — When 
employed  in  the  former  way  the  fulcrum  is  intended  to  be 
the  hand  of  the  operator ;  but  the  risk  of  using  the  mater- 
nal structures  as  a  point  dUippui,  and  the  inevitable  danger 
of  contusion  and  laceration  which  must  follow,  constitute 
one  of  the  chief  objections  to  the  operation.  Its  value  as 
a  tractor  must  always  be  limited  and  quite  inferior  to  that 
of  the  forceps,  while  it  is  as  difficult  to  introduce  and  man- 
ipulate. 

Cases  in  which  it  is  Ap])licable. — The  veetis  has  been 
recommended  in  cases  in  which  the  low  forceps  operation 
is  suitable,  provided  the  pains  have  not  entirely  ceased. 
There  is  no  doubt  that  it  may  be  quite  capable  of  overcom- 
ing a  slight  impediment  to  the  passage  of  the  head.  It  is 
Hinged  iiaiidie.  applied  ovcr  various  parts  of  the  head,  most  commonly 
over  the  occijjut,  in  the  same  manner  and  with  the  same 
precautions  as  one  blade  of  the  forceps.  Dr.  Ramsbotham  says,  "We 
shall  find  it  necessary  to  apply  it  to  different  parts  of  the  cranium,  and 
perhaps  the  face  also,  successively,  in  order  to  relieve  the  head  from  its 
fixed  condition  and  favor  its  descent."  Such  an  operation  obviously 
requires  quite  as  much  dexterity  as  the  application  of  the  forceps  ;  while, 
if  we  bear  in  mind  its  comparatively  slight  power  and  the  risk  of 
injury  to  the  maternal  structures,  we  must  admit  that  the  disuse  of  the 
instrument  in  modern  practice  is  amply  justified. 

Is  Sometimes  of  Value  in  Correcting  Malpositions  of  the  Head. — The 
veetis  may,  however,  find  a  useful  application  when  employed  to  rectify 
malpositions,  especially  in  certain  occipito-posterior  presentations.  This 
action  of  the  instrument  has  already  been  considered  (p.  320),  and  under 
such  circumstances  it  may  prove  of  service  where  the  forceps  is  inapplic- 
able. When  so  employed  it  is  passed  carefully  over  the  occiput,  and, 
while  the  maternal  structures  are  guarded  from  injury,  downward  trac- 
tion is  made  during  the  continuance  of  a  pain.  So  used,  its  ai)plication 
is  perfectly  simple  and  free  from  danger,  and  for  this  purpose  it  may  be 
retained  as  part  of  the  obstetric  armamentarium. 

The  Fillet. — The  fillet  is  the  oldest  of  obstetric  instruments,  having 
been  frequently  employed  before  the  invention  of  the  forceps,  and  even 
in  the  time  of  Smellie  it  was  much  used  in  the  metropolis.  It  has  since 
completely  fiillen  out  of  fiivor  as  a  scientific  instrument,  although  its  use 
is  every  now  and  again  advocated  ;  and  it  is  certainly  a  favorite  instru- 
ment with  some  practitioners.  This  is  to  be  explained  by  the  apparent 
simplicity  of  the  operation  and  the  fact  that  it  can  generally  be  per- 
formed without  the  knowledge  of  the  patient.  The  latter,  however,  is 
one  strong  reason  why  it  should  not  be  used. 

Nature  of  the  Instrument. — The  fillet  consists,  in  its  most  improved 


OPERATIONS  INVOLVING  DESTRUCTION  OF  FCETUS. 


497 


Fig.  176. 


form  (that  which  is  recommended  by  Dr.  Eardley  Wilmot/  Fig.  176), 
of  a  slip  of  whalebone  fixed  into  a  handle  composed  of  two  separate 
halves,  which  join  into  one.  The  whalebone 
loop  is  slipped  over  either  the  occijjut  or  face, 
and  traction  used  at  the  handle. 

Objections  to  its  Use. — When  applied  over 
the  face  after  the  head  has  rotated  it  would 
probably  do  no  harm,  but  if  it  were  so  placed 
when  the  head  was  high  in  the  pelvis,  traction 
would  necessarily  produce  extension  of  the 
chin  before  the  proper  time,  and  would  thus 
interfere  with  the  natural  mechanism  of  de- 
livery. If  placed  over  the  occiput,  it  is  im- 
possible to  make  traction  in  the  direction  of 
the  pelvic  axes,  as  the  instrument  will  then 
infallibly  slip.  If  traction  be  made  in  any 
other  direction,  there  must  be  a  risk  of  injur- 
ing the  maternal  structures  or  of  changing 
the  j)osition  of  the  head.  Hence  there  is 
every  reason  for  discarding  the  fillet  as  a  trac- 
tor or  as  a  substitute  for  the  forceps,  even  in 
the  simplest  cases. 

Its  Use  in  Certain  3IaIpositions  of  the  Head. 
— It  is  quite  possible  that  it  may  find  a  use- 
ful application  in  certain  cases  in  which  the 
vectis  may  also  be  used — viz.  as  a  rectifier  of  malposition ;  and  from 
the  comparative  facility  of  its  introduction  it  would  probably  be  the 
preferable  instrument  of  the  two. 


m 


L*^' 


Wilmot's  Fillet. 


CHAPTER  V. 


OPEKATIONS  INVOLVING  DESTRUCTION  OF  THE  FCETUS. 


Operations  involving  the  destruction  and  mutilation  of  the  child 
were  among  the  first  practised  in  midwifery.  Craniotomy  was  evidently 
known  in  the  time  of  Hippocrates,  as  he  mentions  a  mode  of  extracting 
the  head  by  means  of  hooks.  Celsus  describes  a  similar  operation,  and 
was  acquainted  with  the  manner  of  extracting  the  foetus  in  transverse 
presentations  by  decapitation.  Similar  procedures  were  also  practised 
and  described  i)y  Aetius  and  others  among  the  ancient  writers.  The 
physicians  of  the  Arabian  school  not  only  employed  perforators  for 
oj)(;niiig  the  heyd,  l)ut  were  acquainted  with  instruments  for  compressing 
and  extracting  it. 

lielic/ious  Objections  to  Craniotomy. — Until  the  end  of  the  seventeenth 

'  OhHl.  Tram.,  vol.  .xv. 
•62 


498  OBSTETRIC  OPERATIONS. 

century  this  class  of  operation  was  not  considered  justifiable  in  the  case 
of  living  children ;  it  then  came  to  be  discussed  whether  the  life  of  the 
child  might  not  be  sacrificed  to  save  that  of  the  mother.  It  was  author- 
itatively ruled  by  the  Theological  Faculty  of  Paris  that  the  destruction 
of  the  child  in  any  case  was  mortal  sin  :  "  Si  I'on  ne  pent  tirer  I'enfant 
sans  le  teur,  on  ne  peut  sans  peche  mortel  le  tirer."  This  dictum  of  the 
Roman  Church  had  great  influence  on  continental  midwifery,  more  espe- 
cially in  France,  where,  up  to  a  recent  date,  the  leading  obstetricians 
considered  craniotomy  to  be  only  justifiable  when  the  death  of  the  fetus 
had  been  positively  ascertained.  Even  at  the  present  day  there  are  not 
wanting  practitioners  who  in  their  praiseworthy  objection  to  the  destruc- 
tion of  a  living  child  counsel  delay  until  the  child  has  died — a  practice 
thoroughly  illogical,  and  only  sparing  the  operator's  feelings  at  the  cost 
of  greatly-increased  risk  to  the  mother.  In  England  the  safety  of  the 
child  has  always  been  considered  subservient  to  that  of  the  mother ;  and 
it  has  been  admitted  that  in  every  case  in  which  the  extraction  of  a 
living  foetus  by  any  of  the  ordinary  means  is  impossible  its  mutilation 
is  perfectly  justifiable. 

Its  Unjustifiable  Frequency. — It  must  be  admitted  that  the  frequency 
with  which  craniotomy  has  been  performed  in  this  country  constitutes  a 
great  blot  on  British  midwifery.  During  the  mastership  of  Dr.  Labbat 
at  the  Rotunda  Hospital  the  forceps  was  never  once  applied  in  21,867 
labors.  Even  in  the  time  of  Clarke  and  Collins,  when  its  frequency  was 
much  diminished,  craniotomy  was  performed  three  or  four  times  as  often 
as  forceps  delivery.  These  figures  indicate  a  destruction  of  fcetal  life 
which  we  cannot  look  back  to  without  a  shudder,  and  which,  it  is  to  be 
feared,  justify  the  reproaches  which  our  continental  brethren  have  cast 
upon  our  practice.  Fortunately,  professional  opinion  has  now  com- 
pletely recognized  the  sacred  duty  of  saving  the  infant's  life  ^^Ilenever 
it  is  practicable  to  do  so  ;  and  British  obstetricians  now  teach,  as  care- 
fully as  those  of  any  other  nation,  the  imperative  necessity  of  using 
every  endeavor  to  avoid  the  destruction  of  the  foetus. 

Divisions  of  the  Subject. — The  operation  now  under  consideration  may 
be  necessary — 1st,  when  the  head  requires  either  to  be  sim]jly  perforated 
or  ^afterward  more  completely  broken  up  and  extracted-— an  operation 
which  has  received  various  names,  but  is  generally  known  in  this  coun- 
try as  craniotomiu  and  which  may  or  may  not  require  to  be  followed 
by  further  diminution  of  the  trunk.  2dly,  when  the  arm^pre^eiiia-ajld 
turning  is  impossible.  This  necessitates  one  of  two  procedures — decap- 
itation with  the  separate  extraction  of  the  body  and  head,  or  erisceratign. 
In  both  classes  of  cases  similar  instrmnents  are  employed,  and  those 
generally  in  use  at  the  present  time  may  be  first  briefly  described. 

Description  of  Instruments  Einploi/erl. — 1.  Perforator. — The  object  of 
the  perforator  is  to  pierce  the  skull  of  the  child,  so  as  to  admit  of  the 
brain  being  broken  up  and  the  consequent  collapse  and  diminution  in 
size  of  the  cranium.  The  perforator* invented  byDenman  or  some  mod- 
ification of  it  has  been  principally  employed.  It  requires  the  handles  to 
be  separated  in  order  to  open  the  blades,  and  this  cannot  be  done  by  the 
operator  himself  This  difficulty  is  overcome  in  the  modification  of 
Naegele's  perforator  used  in  Edinburgh,  in  which  the  handles  are  so 


OPERATIONS  INVOLVING  DESTRUCTION  OF  F(ETU8. 


499 


constructed  that  they  open  the  points  when  pressed  together,  and  are 
separated  by  a  steel  rod,  with  a  joint  at  its  centre  to  prevent  their  open- 


FiG.  177. 


Fig.  178. 


Fig.  179. 


Figs.  180, 181. 


Various  Forms  of  Perforators. 

ing  too  soon.  By  this  arrangement  the  instrument  can  be  manipulated 
by  one  hand  only.  The  sharp-pointed  portion  has  an  external  cutting 
edge,  with  projecting  shoulders  at  its  base  to  prevent  its 
penetrating  too  far  into  the  cranium.  Many  modifica- 
tions of  these  arrangements  have  since  been  contrived 
(Figs.  177,  178,  179).  In  some  parts  of  the  Continent 
a  perforator  is  used  constructed  on  the  principle  of  the 
trephine ;  but  this  is  vastly  more  difficult  to  work,  and 
has  the  great  disadvantage  of  simply  boring  a  hole  in 
the  skull,  instead  of  splitting  it  up,  as  is  done  by  the 
sharp-poi  nted  i  nst  rumen t . 

The  instruments  for  extraction  are  the  crotchet  and 
craniotomy  forceps. 

Crotchets  and  Craniotomy  Forceps, — The  crotchet  is 
a  sharp-pointed  hook  of  highly-tempered  steel,  which 
can  be  fixed  on  some  portion  of  the  skull,  either  inter- 
nal or  external,  traction  being  made  by  the  handle. 
The  shank  of  the  instrument  is  either  straight  or 
curved  (Figs.  180  and  181),  the  latter  being  preferable, 
and  it  is  either  attached  to  a  wooden  handle  or  forged 
in  a  single  piece  of  metal.  A  modification  of  this  in- 
strument is  known  as  Oldham's  vertebral  hook.  It  con- 
sists of  a  slender  hook,  measuring,  with  its  handle,  13 
inches  in  length,  which  is  passed  through  the  fi)ramen 
niagninn  and  fix(!d  in  thci  vertebral  canal,  so  as  to 
secure  a  firm  hold  for  traction.  All  forms  ojr_cr(>t chefs 
are  open  to  the  serious  objection  of  Ixiino^  Tial)l<!  to  sli,) ) 
or  break,  through  the  bone  to  which  tluy  are  fix(!(l,  so  wounding  either 


%J 


(Jrotcliets. 


500 


OBSTETRIC  OPERATIONS. 


Fig.  183. 


the  soft  parts  of  the  mother  or  the  fingers  of  the  operator  placed  as  a 
guard.  Hence  they  are  discountenanced  by  most  recent  writers,  and 
may  with  propriety  be  regarded  as  obsolete  instruments. 

Oraniotomy  Forxej)s  are  Prefeiuble  for  Extraction. — Their  place  as 
tractors  is  well  supplied  by  the  more  modern  craniotomy  forceps  (Fig. 
182).  These  are  intended  to  lay  hold  of  the  skull,  one  blade  being 
introduced  within  the  cranium,  the  other  externally,  and  when  a  firm 
grasp  has  been  obtained  downward  traction  is  made.  A  second  object 
it  fulfils  is  to  break  away  and  remove  portions  of  the  skull  ^^'hen 
perforation  and  traction  alone  are  insufficient  to  effect  delivery. 
Many  tbrms  oi'  craniotomy  forceps  are  in  use — some  armed  with 
formidable  teeth ;  others,  of  simpler  construction,  depending  on  their 
roughened  and  serrated  internal  surfaces  for  firmness  of  grasp.  For 
general  use  there  is  no  better  instrument  than  the  craniodad  of  Sir 

James  Simpson  (Fig.  183),  which  ad- 
mirably fulfils  both  these  indications. 
It  consists  of  two  separate  blades  fast- 
ened by  a  button  joint.  The  extrem- 
ities of  the  blades  are  of  a  duck-billed 
shape,  and  are  sufficiently  curved  to 
allow  of  a  firm  grasp  of  the  skull 
being  taken :  the  upper  blade  is  deep- 
ly grooved  to  allow  the  lower  to  sink 
into  it,  and  this  gives  the  instrument 
great  po^^'er  in  fracturing  the  cranial 
bones  when  that  is  found  to  be  neces- 
sary. It  need  not,  however,  be  em- 
ployed for  the  latter  purpose,  and,  the 
blades  beinp;  serrated  on  their  under 
surface,  form  as  perfect  a  pan-  of  cra- 
niotomy forceps  as  any  in  ordinary 
use.  Provided  with  it,  we  are  spared 
the  necessity  of  procuring  a  number 
of  instruments  for  extraction. 

Cephalotribc. — Amongst  modern  im- 
provements in  midwifery  there  are  few  which  have  led  to  more  discus- 
sion than  the  use  of  the  cephalotribe.  This  instrument,  originally  in- 
vented by  Baudelocque,  was  long  employed  on  the  Continent  before  it 
was  used  in  this  country,  the  prejudice  against  it  being  no  doubt  due  to 
its  formidable  size  and  appearance.  Of  late  years  many  of  our  leading 
obstetricians  have  used  it  in  preference  either  to  the  crotchet  or  crani- 
otomy forceps,  and  have  materially  modified  and  improved  its  construc- 
tion, so  that  the  most  objectionable  features  of  the  older  instruments  are 
now  entirely  removed. 

Object  of  the  Instrument. — The  ceplialotribe  consists  of  two  powerful 
solid  blades,  which  are  applied  to  the  head  after  perforation  and  ap- 
proximated by  means  of  a  screw  so  as  to  crush  the  cranial  bones,  and 
after  this  it  may  be  also  used  for  extraction.  The  pponlinr  value  of 
the  instrument  is  that  when  properly  applied  it  crushes  the  firm  basis 
of  the  skull,  which  is  left  untouched  by  craniotomy ;  or,  if  it  does  not, 


Craniotomy  Forceps. 


Simpson's  Cranio- 
clast. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  FCETUS. 


501 


Fig.  184. 


it  at  least  causes  the  base  to  turn  edgeways  within  the  blades,  so  as  to 
be  in  a  more  favorable  position  for  extraction.  Another  and  specially 
valuable  property  is  that  it  crushes  the  bones  vifhi)i  the  scalp,  which 
forms  a  most  efficient  protective  covering;  to  their  sharp  edges.  In  this 
way  one  of  the  principal  dangers  of  craniotomy — the  wounding  of  the 
maternal  passages  by  spiculse  of  bone — is  entirely  avoided. 

Some  Obstetricians  Object  to  Using  it  as  a  Tractor. — The  cephalotribe, 
therefore,  acts  in  two  ways — as  a  crusher  and  as  a  tractor.  "Some  obstet- 
ricians  believe  the  former  to  be  its  more  important  use,  and  even  main- 
tain that  the  cephalotribe  is  unsuited  for  traction.  This  view  is  specially 
maintained  by  Pajot,  who  teaches  that  after  the  size  of  the  skull  has 
been  diminished  by  repeated  crushings  its  expulsion  should  be  left  to 
the  natural  powers.  There  are  some  grounds  for  believing  that  in  the 
greater  degrees  of  obstruction  the  tractile  power  of  the  instrument  should 
not  be  called  into  use ;  but  in  the  large  majority  of  cases  the  facility 
with  which  the  crushed  head  may  be  withdrawn  by  it  constitutes  one  of 
its  chief  claims  to  the  attention  of  the  obstetrician.  No  one  who  has 
used  it  in  this  way,  and  experienced  the  rapid  and  easy  manner  in  which 
it  accomplishes  delivery,  can  have  any  doubt  on  this  point. 

Its  Value. — There  is  every  reason  to  believe  that  cephalotripsy  will  be 
much  extended  in  this  country,  and  that 
it  will  be  considered,  as  I  believe  it  un- 
questionably deserves  to  be,  the  ordinary 
operation  in  cases  requiring  destruction 
of  the  foetus.  The  comparative  merits 
of  cephalotripsy  and  craniotomy  will  be 
subsequently  considered. 

Description  of  the  Instrument. — The 
most  perfect  cephalotribe  is  probably  that 
known  as  Braxton  Hicks'  (Fig.  184), 
which  is  a  modification  of  Simpson's. 
It  is  not  of  unwieldy  size,  but  sufficiently 
powerful  for  any  case,  and  not  extrava- 
gant in  price.  The  blades  have  a  slight 
pelvic  curve,  which  materially  facilitates 
their  introduction,  yet  not  sufficiently 
marked  to  interfere  with  their  being 
slightly  rotated  after  application.  Dr. 
Kidd  of  Dublin  prefers  a  straight  blade, 
while  Dr.  Matthews  Duncan  thinks  it 
better  to  use  a  somewhat  bulkier  instru- 
ment, modelled  on  the  type  of  the  conti- 
nental ce])halotribes.  The  principle  of  ac- 
tion of  all  tiiesc  is  identical,  and  their  diffi^jr- 
ences  are  not  of  very  niat(!rial  importance. 

Section  of  t/ie  Skull  Inj  the  Forceps 
Savj  or  EcrascMr. — Anotlier  in(jde  of 
diminishing  the  foetal  skull  is  by  remov- 
ing it  in  sections.  The  object  is  aimed 
at  in   th(i  forceps  saw  of  Van    iruevel,  nicks' Cephalotribe. 


502  OBSTETRIC  OPERATIONS. 

which  consists  of  two  large  blades  not  unlike  those  of  the  cephalotribe 
in  appearance.  Within  these  there  is  a  complicated  mechanism  working 
a  chain-saw  from  below  upward,  which  cuts  through  the  foetal  skull ; 
the  separated  portions  are  subsequently  withdrawn  piecemeal.  This 
instrument  is  highly  spoken  of  by  the  Belgian  obstetricians,  who  believe 
that  it  affords  by  far  the  safest  and  most  effectual  way  of  reducing  the 
bulk  of  the  foetal  skull.  In  this  country  it  is  practically  unknown, 
and,  although  it  must  be  admitted  to  be  theoreticallv  excellent,  the  com- 
plexity  and  cost  of  the  apparatus  have  always  stood  in  the  way  of  its 
being  used. 

Dr.  Barnes  has  suggested  that  the  same  results  may  be  obtained  by 
dividing  the  head  with  a  strong  wire  ^craseur.  So  far  as  I  know,  this 
suggestion  has  never  yet  been  carried  out  in  practice,  not  even  by  himself, 
and  therefore  it  is  not  possible  to  say  much  about  it.  I  should  imagine, 
however,  that  there  would  be  considerable  difficulty  in  satisfactorily 
passing  the  loop  of  wire  over  the  skull  in  a  pelvis  in  ^^'hich  there  is  any 
well-marked  deformity. 

Cases  Requiring  Craniotomy. — The  most  common  cause  for  which 
craniotomy  or  cephalotripsv  is  performed  is  a  want  of  proper  proi3ortion 
between  the  tiead  and  the  maternal  pns^ges.  This  may  arise  from  a 
variety  of  causes.  The  most  iinp<trtaiit,  ana  that  most  often  necessitating 
the  operation,  is  osseous  defi  >i'niity.  This  may  exist  either  in  the  brim, 
cavit}',  or  outlet,  and  it  is  most  often  met  with  in  the  antero-postei-ior 
dianictcT  of  the  brim.  Obstetric  autliorities  differ  considerably  as  to  the 
precise  amount  of  contraction  m  Inch  will  prevent  the  passage  of  a  living 
child  at  term.  Thus,  Clarke  and  Burns  believe  that  a  living  child  can- 
not pass  through  a  pelvis  in  M'hich  the  antero-posterior  diameter  at  the 
brim  is  less  than  3|-  inches  ;  Ramsbotham  fixes  the  limit  at  3  inches,  and 
Osborne  and  Hamilton  at  2f  inches.  The  latter  is  the  extreme  limit  at 
which  the  birth  of  a  living  child  is  possible ;  but  there  can  be  no  doubt 
that  under  favorable  circumstances  it  may  be  possible  to  draw^  the  foetus, 
after  turning,  through  a  pelvis  of  that  size.  The  opposite  limit  of  the 
operation  is  still  more  open  to  discussion.  Various  authorities  have 
considered  it  (juito  2)()ssil)le  to  draAv  a  mutilated  foetus  through  a  pelvis 
in  which  the  ;uit('r()-]M)st('ri(>r  diameter  docs  not  exceed  1^  inches,  and, 
indeed,  have  succeeded  in  doing  so.  ])ut  then  there  must  be  a  fair 
amount  of  space  in  the  transNcrse  diameter  of  the  pelvis  to  admit  of  the 
necessary  manipulations.  If  there  be  a  clear  space  here  of  3  inches  and 
upward,  it  is  no  doubt  possible  to  deliver  per  vias  nahirales;  but  in  such 
extreme  deformities  the  difficulties  are  so  great,  and  the  bruising  of  the 
maternal  structures  so  extensive,  that  it  becomes  an  operation  of  the 
greatest  possible  severity,  with  results  nearly  as  unfavorable  to  the  mother 
as  the  Csesarean  section.  Hence  some  continental  authorities  have  not 
scrupled  to  jirefer  the  latter  operation  in  the  worst  forms  of  pelvic 
deformity.  The  rule  in  English  practice  always  has  been  that  crani- 
otomy must  be  performed  whenever  it  is  practicable ;  and  there  can  be 
no  doubt  that  it  is  the  right  one. 

Limits  of  the  Operation. — Between  from  2|  tq_3  inches  antero-posterior 
dianieter  in  onedirectjon^|-  inches  in  the  other,  may  l^e  said  to  be  the 
limits  of  craniotomy,  provided,  in  the  latter  case,  tliere  be  a  fair  amount 


OPERATIONS  INVOLVING  DESTRUCTION  OF  FCETUS.        503 

of  space  in  the  transverse  diameter.     The  same  limits  may  be  laid  doM^n 
with  regard  to  tnmors  or  other  sources  of  obstruction. 

Other  Causes  Justifying  Craniotomy. — There  are  a  few  other  conditions 
iii^ which  craniotomy  is  justifiable,  indepen^fcntly^ of^23elvic  contrai -t i ( )n . 
such  as  certain  conditions  of  the  soft  parts  whieli  are  supjxJsed  to  render 
the  passaoQ  of  tlie  lioad  jx'culiarlv  (langeruus  to  the.  iiwtJier.  Among 
them  may  be  mentioned  s\\e]liiig_^  and  inflapniiation  of  the  vagina  from  ' 
the  length  of  the  previous  labor,  bands  and  cicatrices  of  the  vagina,  and 
orclnsiou  and  rityjditv  of  the  os.  It  is  hardly  too  much  to  say  that  with  J 
a  proper  use  of  the  resources  of  midwifery  the  destruction  of  a  living 
foetus  for  any  of  these  conditions  might  be  obviated.  The  most  common 
of  them  is  undoubtedly  swelling  of  the  soft  parts  causing  impaction  of 
the  head — an  occurrence  which  ought  to  be  invariably  prevented  by  a 
timely  use  of  the  forceps.  Should  interference  unfortunately  be  delayed 
until  impaction  has  actually  taken  place,  doubtless  no  other  resource  but 
craniotomy  would  be  left ;  but  such  cases,  it  is  to  be  hoped,  are  now  of 
rare  occurrence  in  British  practice.  Undue  rigidity  of  the  os  can  be 
overcome  by  dilatation  with  the  caoutchouc  bags,  or,  in  more  serious 
cases,  by  incision,  which  would  certainly  be  less  perilous  to  the  mother 
than  dragging  even  a  mutilated  foetus  through  the  small  and  rigid  aper- 
ture. In  the  case  of  bands  and  cicatrices  in  the  vagina,  dilatation  or 
incision  will  generally  suffice  to  remove  the  obstruction  ;  but  even  were 
this  not  so,  here,  as  in  excessive  rigidity  of  the  perineum,  it  Avould  be 
better  that  slight  lacerations  should  take  place  than  that  the  child  should 
be  killed. 

Certain  Complications  of  Labor  are  held  to  Justify  Craniotomy. — Cer-  y 
tain  complications  of  labor  are  held  to  j  ustify  craniotomy,  such  as_rup-/ 
ture  of  the  uterus,  convulsions,  and  hemorrhage.  The  application  ofj 
the  forceps  or  turning  will  generally  answer  our  purpose  equally  well, 
especially  as  we  have  the  means  of  dilating  the  os  sufficiently  to  admit 
of  one  or  other  of  them  being  performed  when  the  natural  dilatation  is 
not  sufficient.  Craniotomy  in  rupture  of  the  uterus  will  also  be  rarely 
indicated,  as  we  have  seen  that  gastrotomy  appears  to  aflPord  a  better 
chance  to  the  mother  in  those  cases  in  which  the  foetus  has  partially  or 
entirely  escaped  from  the  uterine  cavity. 

Excessive  Size  of  the  Foetus  may  require  the  Operation. — Want  of  pro- 
portion between  the  foetus  and  the  pelvis,  depending  on  undue  size  of 
the  head,  either  natural  or  the  result  ofliisease,  may  render  the  operation_ 
essential.  In  the  former  of  these  cases  we  shall  generally  have  first 
attempted  delivery  with  the  forceps,  and  if  it  has  failed  there  can  be  no 
doubt  as  to  the  propriety  of  lessening  the  bulk  of  the  head  by  perforation. 
Craniotomy  when  the  Child  is  believed  to  be  Dead. — In  most  obstetric 
works  we  are  reconmiendcd  to  perforate  rather  than  apply  the  forceps 
wlien  we  are  convinced  that  the  vhWd  luis  ceased  to  live.  This  advice  is 
based  on  th(!  greater  facility  with  wliicli  craniotomy  can  be  performed 
and  its  suj>pos(!(l  gniater  safiity  to  the  mother.  Tliere  can  be  no  doubt 
of  tli(!  ease  witli  which  the  cliild  can  be  extracted  after  perforation  wlien 
th(!  pelvis  is  not  contracted;  and,  if  we  could  always  be  sure  of  our 
diagnosis,  the  rule  might  be  a  good  one.  Before  acting  on  it,  however, 
we  must  bear  in  mind  the  extreme  difficulty  of  ])ositively  ascertaining 


504  OBSTETRIC  OPERATIONS. 

the  death  of  the  foetus.  Of  the  signs  usually  relied  on  for  this  purpose 
there  are  scarcely  any  Mdiich  are  not  open  to  fallacy  except  peeling  of  the 
scalp  and  disintegration  of  the  cranial  bones,  which  do  not  take  place 
unless  the  child  has  been  dead  for  a  length  of  time,  and  are  therefore 
useless  in  most  instances.  Discharge  of  the  meconium  constantly  takes 
place  when  the  child  is  alive ;  a  cold  and  pulseless  prolapsed  cord  may 
belong  to  a  twin  ;  and  the  foetal  heart  may  become  temporarily  inaudil)le 
although  the  child  is  not  dead.  If,  indeed,  we  have  carefully  A\atched 
the  foetal  heart  all  through  the  labor,  and  heard  it  become  more  and 
more  feeble,  and  finally  stop  altogether,  we  might  be  certain  that  the 
child  has  died ;  but  surely  such  observations  w^ould  rather  indicate  an 
early  recourse  to  the  forceps  or  version,  so  as  to  obviate  the  fatal  result 
we  know  to  be  impending. 

Perforation  of  the  After-coming  Head. — In  certain  breech  jDresenta- 
tions  or  after  turning  it  may  be  found  impossible  to  extract  the  head 
without  diminishing  its  size  by  perforating  behind  the  ear.  In  such 
cases  we  know  to  a  certainty  whether  the  child  be  alive  or  dead  before 
resorting  to  the  operation. 

Perforation  is  an  Essential  Preliminary  both  in  Craniotomy  and 
Cephalotripsy. — The  first  step,  whether  w^e  resort  to  cephalotrinsv  or 
craniotomy,  is  perforatioji.  which  will  therefore  be  first  descnbed.  In 
the  former  the  desirability  of  first  perforating  the  head  is  not  always 
recognized.  To  endeavor  to  crush  the  head  w^ithout  perforating  is  need- 
lessly to  increase  the  difficulties  of  the  case,  and  it  should  be  remembered, 
as  a  cardinal  rule,  that  perforation  is  an  essential  preliminary  to  the 
proper  use  of  the  cephalolidbe. 

Method  of  Perforation. — Before  perforating  we  must  carefully  ascer- 
taiii  the  exact  relation  of  the  os  to  the  present  ingpart.  since  in  many 
cases  the  operation  is  performed  before  the  os  is  fully  dilated,  when  there 
is  a  risk  of  wounding  the  cervix.  Two  or  more  fingers  of  the  left  hand 
should  be  passed  up  to  the  head  and  placed  against  the  most  prominent 
part  of  the  parietal  bone.  Under  these,  usecl  as  guard  (Fig.  185),  the 
perforator  should  be  cautiously  introduced  until  the  scalp  is  reached. 
It  is  important  to  fix  on  a  bony  part  of  the  skull,  and  not  on  a  suture 
or  fontanelle,  for  puncture,  because  our  object  is  to  break  up  the  vault 
of  the  cranium  as  much  as  possible,  so  as  to  allows  the  skull  to  collapse. 
When  the  instrument  has  reached  the  point  we  have  selected,  it  should 
be'  made  toftenpfrnte  the  scalp  and  skull  with  a  semi-rotatory  boi-ing 
motion,  and  advanced  until  it  has  sunk  up  to  the  rests,  which  will 
oppose  its  further  progress.  Occasionally  considerable  force  will  be 
necessary  to  effect  penetration,  more  especially  if  the  scalp  be  swollen  by 
long-continued  pressure ;  and  this  stage  of  the  operation  will  be  fagjli- 
tated  by  causing  an  assistant  to  stc-adv  the  head  byT'i-ossure  on  tliejbetus 
througji  the  abdomen,  more  especially  if  it  be  still  five  above  tliFpelvic 
brim.  We  must  then  press  together  the  handles  of  the  instrument, 
which  wdll  have  the  effect  of  widely  separating  the  cutting  portion  and 
making  an  incision  through  the  bones.  After  this  the  point  should 
be  turned  round,  and  again  opened  at  right  angles  to  the  former  incision, 
so  as  to  make  a  free  crucial  opening.  During  this  process  care  must  be 
taken  to  bury  the  perforator  in  the  skull  up  to  the  rests,  so  as  to  avoid 


OPERATIONS  INVOLVING  DESTRUCTION  OF  FCETUS. 


505 


the  possibility  of   injuring  the  maternal  soft  parts.      The  instrument 

should  now  he  introduced  within  the  skull  and  moved  freely  about,  so 

as  to  thoroughly  and  completely  break  up  the  brain.    Especial  care  must 

be  taken  to  reach  tlic  nu'dulla  oblongata  and  base  of"ti5e  brain,  for  if 

these  were  not  destroyed  we  might  subject  ourselves  to  the  distress  of 

extracting  a  child  in  whom  life  was 

not  extinct.    If  this  part  of  the  opera-  ^^^^-  ^^^• 

tion  be  thoroughly  performed,  there 

will  be  no  necessity  for  washing  out 

the  brain  by  the  injection  of  warm 

water,  as  is  sometimes  recommended, 

for  the  broken-up  tissue  will  escape 

freely  through  the  opening  made  by 

the  perforator. 

Perforation  of  the  After-coming 
Head. — The  laerforation  of  the  after- 
coming  head  does~not  generally  oiter 
any  ]3articular  difficulty.  It  is  ac- 
coimplished  In  the  same  manner,  the 
child's  body  being  well  drawn  out  of 
the  way  by  an  assistant.  The  point 
of  the  perforator,  carefully  guarded 
by  the  finger,  is  guided  up  to  the 
occiput  or  behind  the  ear,  where  it  is 
inserted. 

It  is  sometimes  Useful  to  Postpone 
Extraction. — If  there  be  no  necessity 
for  very  rapid  delivery,  and  the  pains 
be  still  present,  it  is  often  advisable  to 
wait  ten  minutes  or  a  quarter  of  an 
hour  before  proceeding  to  extract. 
This  delay  will  allow  the  skull  to 
collapse  and  become  moulded  to  the 
cavity  of  the  pelvis  when  forced  down 
by  the  pains,  and  possibly  the  natural  effort  may  suffice  to  finish  the 
labor  in  that  time;  or  at  least  the  head  will  have  descended  farther, 
and  will  be  in  a  better  position  for  extraction.  Should  perforation  be 
required  after  having  failed  to  deliver  with  the  forceps — and  this  is  only 
liJvcly  to  be  the  case  when  the  obstruction  is  comparatively  slight — it  is 
w^rtainly  a  good  plan  to  perforate  without  removing  the  forceps,  which 
may  tlien  be  used  as  tractors. 

We  have  now  to  decide  on  the  method  of  extraction ;  and  our  choice 
generally  lies  between  the  cephalotribc  and  the  craniotomy  forceps, 
altliougli  in  some  few  cases,  in  whicli  the  pelvic  contraction  is  slight, 
version  may  be  advantageously  employed. 

(Jo'inparatire  3ferits  of  ('eplialotrij)sy  and  Cramotomy. — Those  who 
have  used  both  nuist,  T  think,  admit  that  in  any  ordinary  case,  in  which 
the  obstruction  is  not  great  and  only  a  comparatively  slight  diminution 
in  the  size  of  the  head  is  rcfpiired,  cephalotripsy  is  infinitely  the  easier 
operation.     Tiic  fiicility  with  whidi  the  skull  can   be  crushed   is  some- 


Perforation  of  the  Skull. 


506  OBSTETRIC  OPERATIONS. 

times  remarkable,  and  those  who  will  take  the  trouble  to  read  the  reports 
of  the  operation  published  by  Braxton  Hicks,  Kidd,  and  others  cannot 
fail  to  be  struck  with  the  rapidity  with  which  the  broken-down  head 
may  often  be  extracted.  This  is  far  from  being  the  case  Avitli  the  crani- 
otomy forceps,  even  when  the  obstruction  is  moderate  only ;  for  it  may 
be  necessary  to  use  considerable  traction,  or  the  blades  may  take  a  proper 
grasp  M'ith  difficulty,  or  it  may  be  essential  to  break  down  and  remove 
a  considerable  portion  of  the  vault  of  the  cranium  before  the  head  is 
lessened  sufficiently  to  pass.  During  the  latter  process,  however  care- 
fully performed,  there  is  a  certain  risk  of  injuring  the  maternal  struc- 
tures, and  in  the  hands  of  a  nervous  or  inexperienced  operator  this 
danger,  which  is  entirely  avoided  in  cephalotripsy,  is  far  from  slight. 
The  pas^ge  of  the  blades  of  jdie.ce^Dhalot^  is  by  no  means  difiicult. 
and  I  think  it  mustlBe  admitted  that  the  i30ssible  risks  attending  it  are 

nil     iiiiMi^i»«i^    iwM^^i iiiMi^ig f*^m 

comparatively  small.  On  account,  therefore,  of  its  simplicity  and  safety 
to  the  maternal  structures,  I  believe  (•e])luilotripsy  to  be  decidedly^the 
preferal)le  operation   in  all  cases  of  moderate  obstruction. 

When  we  approach  the  lower  limit,  and  have  to  do  with  a  very  marked 
amount  of  pelvic  deformity,  the  two  operations  stand  on  a  more  equal 
footing.  Then  the  deformity  may  be  so  great  as  to  render  it  difficult 
to  pass  the  blades  of  even  the  smallest  cephalotribe  sufficiently  deep 
to  grasp  the  head  firmly,  and  even  when  they  are  passed  the  space  is 
often  so  limited  as  to  impede  the  easy  working  of  the  instrument. 
Besides  this,  repeated  crushings  may  be  required  to  diminish  the  skull 
sufficiently.  I  attach  but  little  importance  to  the  argument  that  the 
diminution  of  the  skull  in  one  diameter  increases  its  bulk  in  another. 
The  necessity  of  removing  and  replacing  the  blades  on  another  part  of 
the  skull,  and  of  r^eating  this  perhaps  several  times  in  the  manner 
recommended  by  ^jot,  is  a  far  more  serious  objection.  To  do  this  in 
a  contracted  pelvis  involves,  of  necessity,  the  risk  of  much  contusion. 
Fortunately,  cases  of  this  kind  are  of  extreme  rarity — much  more  so 
than  is  generally  believed — but  when  they  do  occur  they  tax  the  resources 
of  the  practitioner  to  the  utmost. 

Oii^the  wliole^  the  conclusion  T  would  be  inclined  to  arrive  nt^jvith 
regard  to  the  two  operations  is,  tliat  in  all  ordinary  cases  cephalotri]3SV 
iS  safer  and  easier,  wlici'ciis  in  cases  with  considerable  pelvic  deformity 
the  advantages  of  ce])linloti-!])sy  are_llot_so^\; ell  marked,  and  craniotomy 
may  (,'ven  prove  to  be  jn'cierable. 

J}esci-ij)ti())i  of  the  Ojjcrafion. — The  first  step  in  using  the  cephalotribe 
is  the  passage  of  the  blad^.  These  are  tol)e  inserted  in  precisely  the 
same  manner  and  with  the  same  ])recautions  as  in  the  high  forceps 
operatioii.  In  many  cases  the  os  is  not  fully  dilated,  and  it  is  absolutely 
essential  to  pass  the  instrument  within  it.  Special  care  should  therefore 
be  taken  to  avoid  any  injury  to  its  edges,  and  for  this  purpose  two  or 
three  fingers  of  the  left  hand,  or  even  the  whole  hand,  should  be  passed 
high  up,  so  as  thoroughly  to  protect  the  maternal  structures.  In  order 
that  the  base  of  the  skull  may  be  reached  and  effectually  crushed,  the 
blades  must  be  deeply  inserted  ;  and  in  doing  this  great  care  and  gentle- 
ness must  be  used.  As  the  projecting  promontory  of  the  sacrum 
generally  tilts  the  head  forward,  the  handles  of  the  instrument,  after 


OPERATIONS  INVOLVING  DESTRUCTION  OF  FCETUS.        507 


Fig.  186. 


lockiiiii',  must  be  well  pressed  backward  toward  the  perineum.  If  the 
blades  do  not  lock  easily,  or  if  any  obstruction  to  their  passage  l)e  ex- 
perienced, one  of  them  must  be  withdrawn  and  reintnxluced,  just  as  in 
forceps  operations.  Care  must  be  taken,  as  the  instrument  is  being  in- 
serted, to  fix  and  steady  the  head  by  abdominal  pressure,  since  it  is 
generall}'  far  above  the  brim,  and  would  readily  recede  if  this  precau- 
tion were  neglected.  When  the  blades  are  in  .situ  we  proceed  to  crush 
byj:urning  the  screw  slpy\d^  and  as  the  blades  are  approximated  the 
bones  yiela  and  the  cephalotribe  sinks  into  the  cranium.  The  crushed 
portion  then  measures,  of  course,  no  more  than  the  thickness  of  the 
blades — that  is,  about  IJ  inches.  This  is  necessarily  accompanied  by 
some  bulging  of  the  part  of  the  cranium  that  is  not  within  the  grasp  of 
the  instrument  (Fig.  186),  but  in  slight  de- 
formity this  is  of  no  consequence,  and  we  may 
proceed  to  extraction,  waiting,  if  possible,  for 
a  pain,  and  drawing  at  first  downward  in  the 
axis  of  the  pelvic  inlet,  as  in  forceps  delivery, 
then  in  the  axis  of  the  outlet.  The  site  of 
perforation  should  be  examined  to  see  that  no 
spiculse  of  bone  are  projecting  from  it,  and  if 
so  they  should  be  carefully  removed.  In 
such  cases  the  head  often  descends  at  once  auH 
with  tlic  greatest  ease.  Should  it  not  do  so, 
or  should  the  obstruction  be  considcral)le,^a 
quartei'  turn  should  ))(>  given  to  the  handles 
of  the  instrniiicut,  so  as  to  bring  the  crushed 
portion  into  the  narrower  diameter  and  the 
uncrushed  jtortion  into  the  wider  transverse 
diameter,  it  may  now  be  advisable  to  re- 
move the  blades  carefully,  and  to  reintroduce 
them  with  the  same  precautions,  so  as  to  cmsh 
the  un1)roken  portion  of  the  skull.  This  adds 
materially  to  the  difticulties  of  the  case,  since 
the  blades  have  a  tendency  to  fall  into  the 
deep  channel  already  made  in  the  cranium, 
and  so  it  is  by  no  means  always  easy  to  seize 
tlie  skull  in  a  new  direction.  Before  rcapply- 
in^tlicm,  if  the  condition  of  the  patient  be 
good  and  pains  be  present,  it  may  be  welf^Jo 
wait  an  lioiii'  oi-  more,  in  the  hope  of  the  head 
]jeii)M-  iiionlded  and  pushed  down  into  the 
peK'ie  e;i\-ity.  This  \\a<  ihe  plan  adoptedHi^y 
L>ul>ois,  and,  according  to  Tarnier,  was  the  secret  of  his  great  success  in 
the  operation.  Pajot's  metliod  9l'_i'yH'''t<^.l  ci'Hidnii^  in  the  greater 
<legrees  of  c-ontraction  is  based  on  Ithe  same  idea,  and  he  reccMnmends 
tlmt  the  instrument  should  be  introduced  at  intervals  of  two.  tHree, 
or"  four  hours,  according  to  the  state  oJ  the  patient,  until  the  head  is 
thoroufyhly  crushed,  no  attempts  at  traction  being;  ufied,  and  expulsion 
bein^r  left  to  the  natural  powers.  This,  he  says,  shouIcTaTways  be  done 
wlien  the  contraftion   is  below  2.}  indies,  and  he  maintains  that  it  is 


Foetal  Head  crushed  by  the 
Cephalotribe. 


508 


OBSTETRIC  OPERATIONS. 


Fig.  187. 


quite  possible  to  effect  delivery  by  this  means  when  there  is  only  1-|- 
inehes  in  the  antero-posterior  diameter.  The  repeated  intrqdiiction  of 
the  l)]ades  in  tliis  fashion  must  necessarily  bcniazardous^  except  in  the 
hands  of  a  very  skilful  ojK'i-ator ;  and  I  believe  that  if  a  second  applica- 
tion tail  to  overcome  the  dilticnlty^  which  ^vill  only  be  very  exception- 
ally the  case^  it  would  be  better  to  resort  to  the  measures  presently  t(^be 
described. 

Destruction  of  the  Base  of  the  Skull  from  Within  by  the  Basilyst. — 
Professor  Simj)son  of  Edinburgh^  has  recently  suggested  the  use  of  an 
instrument  which  he  calls  a  "  basilyst."  Its  object  is  to 
break  up  the  base  of  the  foetal  skull  from  within,  after 
the  method  originally  proposed  by  Guyon.  The  screw- 
like portion  of  the  instrument  (Fig.  187),  which  is  in- 
serted through  the  perforation  made  in  the  cranial  vanity 
is  driven  through  the  hard  base,  which  is  then  disin- 
tegrated by  the  separate  movable  blade.  If  experience 
proves  that  this  instrument  can  be  readily  worked,  it 
promises  to  be  a  valuable  addition  to  our  armament- 
arium, since  it  will  effectually  destroy  the  most  resistant 
portion  of  the  skull  without  risk  of  injury  to  the  maternal 
structures,  and  thus  very  materially  facilitate  extraction. 
Extraction  by  the  Craniotomy  Forceps. — Should  we 
elect  to  trust  to  the  craniotomy  forceps  for  extraction^ 
one  blade  is  to  be  introduced  through  the  perforation, 
and  the  other,  in  apposition  to  it,  on  the  outside  of  the 
scfdp.  In  moderate  deformities  ti'action  ap])lied  during 
the  pains  may  of  itself  suffice  to  bring  down  the  head. 
Should  the  obstruction  be  too  great  to  admit  of  this,  it 
is  necessarv  to  l)reak  down  and  remove  the  vault  of  the 
cranium.  For  this  purpose  Simpson's  cranioclast  answers 
better  than  any  other  instrument.  One  of"  the  blades  is  passed  wjtliin 
the  cranium,  the  other,  if  possible,  bet^^'een  the  seal])  and  the  skull,  a_nd 
the  nortion  of  bone  grasped  between  them  is  broken  off ;  this  can  gen- 
eralfy  be  accomplished  by  a  twisting  motion  of  the  Mrist,  m ithout  using 
much  force.  The  separated  portion  of  bone  is  then  extracted,  the  greatest 
care  being  taken  to  guard  the  maternal  structures  during  its  removal  by 
the  fingers  of  the  left  hand.  The  instrument  is  then  applied  to  a  fresh 
part  of  the  skull,  and  the  same  process  repeated,  until  as  much  of  the 
vault  of  the  cranium  as  may  be  necessary  is  broken  up  and  removed. 
Advantages  of  bringing  doivn  the  Face  in  Difficult  Cases. — Dr.  Braxton 
Hicks  ^  has  conclusively  shown  that  in  difficult  cases,  after  the  removal 
of  the  cranial  vault,  the  proper  procedure  is  to  bring  down  the  face, 
since  the  smallest  measurement  of  the  skull  after  the  removal  of  the 
upper  ]>art  of  the  ci'anium  is  from  the  orbital  ridge  to  the  ahcolar  edge 
of  the  su}ierior  maxillarv  bone.  This  alteration  in  the  ])rescntation  he 
proposes  to  etfect  by  a  small  blunt  hook,  made  for  the  purpose,  which  is 
forced  into  the  orbit,  by  means  of  which  the  face  is  made  to  descend. 
Barnes  recommends  that  this  should  be  done  by  fixing  the  craniotomy 
forceps  over  the  forehead  and  face  and  making  traction  in  a  backward 
^Edin.  Med.  Journ.,  April,  1880.  "  Obst.  Tram.,  vol.  vii. 


Professor  Simpson's 
Basilyst. 


OPERATIONS  mVOLVINO  DESTRUCTION  OF  FCETUS. 


509 


Fig.  188. 


Fig.  189. 


direction,  so  as  to  get  the  face  past  the  projecting  promontory  of  the 
sacrum.  The  importance  of  bringing  down  the  face  was  long  ago  pointed 
out  by  Burns,  but  it  had  been  lost  sight  of  until  Hicks  again  drew 
attention  to  it  in  the  paper  referred  to.  In  the  class  of  cases  in  which 
this  procedure  is  valuable  the  risk  to  the  maternal  passages  from  the 
removal  of  the  fractured  portions  of  bone  must  always  be  consider- 
able, and  it  is  of  great  importance  not  only  to  preserve  the  scalp  as 
entire  as  possible,  so  as  to  protect  them,  but  to  use  the  utmost  possible 
care  in  removing  the  broken  j^ieces  of  bone. 

Extraction  of  the  Body. — When  the  extraction  of  the  head  has  been 
effected,  either  by  the  cephalotribe  or  the  craniotomy  forceps,  there  is 
seldom  much  difficulty  with  the  body.  By  traction  on  the  head  one  of 
the  axillse  can  easily  be  brought  within  reach,  and  if  the  body  do  not 
readily  jjass  the  blunt  hook  should  be  introduced  and  traction  made  until 
the  shoulder  is  delivered.  The  same  can  then  be  done  with  the  other 
arm.  If  there  be  still  difficulty,  the  cephalotribe  may  be  used  to  crush 
the  thorax.  The  body  is,  hoAvever,  so  compressible  that  this  is  rarely 
required. 

[The  craniotomy  forceps  chiefly  in  use  with  us  were  devised  by  the 
late  Prof.  Charles  D.  Meigs  for  his  second  operation  upon  Mrs.  Reybold 
of  Philadelphia  in  1833,  and  have  been  used 
repeatedly  since,  either  as  tractors  or  for  redu- 
cing the  size  of  the  foetal  head,  in  cases  of  de- 
formity of  the  pelvis.^  Some  obstetricians  prefer 
the  less  curved  and  broader-bladed  instrument 
•of  Great  Britain  as  a  tractor ;  but  for  the  general 
purposes  of  picking  away  the  cranial  bones  and 
drawing  down  the  base  of  the  skull  in  cases  of 
extreme  pelvic  deformity  there  is  no  more  simple 
appliance  than  that  of  Dr.  Meigs. 

To  act  upon  an  oval  body  like  the  foetal  head 
Dr.  M.  was  obliged  to  prepare  two  forms  of  for- 
ceps— straight  and  curved — to  be  used  as  might 
be  required  according  to  the  part  of  the  skull  to 
be  broken  down  or  drawn  upon.  These  are 
lightlv  made,  serrated,  and  1 2^  inches  in  length. 
—Ed.] 

Einhryotomy  in  Transverse  Presentations  in 
which  Turning  is  Impossible. — There  only  re- 
mains for  us  to  consider  the  second  class  ^f 
d(!stnictive  operations.  These  may  be  necessarv 
in  Iiiii2-ncglcct('(l  cases  of  arm  presentation  in 
wJn(-h  lurning  is  fonnd  to  ])0  ini])racticable. 
Hari',  fortunately,  the  (|nestion  of  killing  th(!  foetus  does  not  arise,  since 
it  will,  almost  necessarily,  have  already  perished  from  the  continuous 
pressiu^e.  We  have  two  (operations  to  select  from — decapitation^  and 
evisceration. 

\}  The  illiistrationH  given  arc  taken  from  tlie  instruments  devised  by  Dr.  Meigs  as  an 
improvement  upon  liis  original  ])attern,  and  will  lie  seen  to  diller  from  those  usually 
presented  in  Ameriean  ohstetrieal  puhlication.s. — Fu.] 


Curved 

Craniotomy 

Forceps. 


510  OBSTETRIC  OPERATIONS. 

Decapitation. — The  former  of  these  is  an  operation  of  great  antiquity, 
having  been  fully  described  Iw  Celsus.  It  consists  in  severing  the  neck, 
so  as  to  sejjarate  the  head  from  the  body ;  the  body  is  then  withdrawn 
by  means  of  the  protruded  arm,  leaving  the  head  in  utero  to  be  subse- 
quently dealt  with.  If  the  neck  can  be  reached  without  great  difficulty 
— and  in  the  majority  of  cases  the  shoulder  is  sufficiently  pressed  down 
into  the  pelvis  to  render  this  quite  possible — there  can  be  no  doubt  that 
it  is  much  the  simpler  and  safer  operation. 

Methods  of  Dioiding  the  Neck. — The  whole  question  rests  on  the  pos- 
sibility of  dividing  the  neck.  For  this  purpose  many  instruments  have 
been  invented.  The  one  generally  recommended  in  this  country  is 
known  as  Ramsbotham's  hook,  and  consists  of  a  sharply-curved  hook 
with  an  internal  cutting  edge.  This  is  guided  over  the  neck,  which  is 
divided  by  a  sawing  motion.  There  is  often  considerable  difficulty  in 
placing  the  instrument  over  the  neck,  although,  if  this  were  done,  it 
would  doubtless  answer  well.  Others  have  invented  instruments,  based 
on  the  principle  of  the  apparatus  for  plugging  the  nostrils,  by  means  of 
^^diich  a  spring  is  passed  round  the  neck,  and  to  the  extremity  of  the 
spring  a  short  cord  or  the  chain  of  an  ecraseur  is  attached  ;  the  spring 
is  then  withdraM-n  and  brings  the  chain  or  cord  into  position.  The 
objection  to  any  of  these  apparatuses  is  that  they  are  unlikely  to  be  at 
hand  when  required,  for  few  practitioners  provide  themselves  with  costly 
instruments  which  they  may  never  require.  It  is  of  importance,  there- 
fore, that  \\&  should  have  at  our  command  some  means  of  dividing  the 
neck  which  is  available  in  the  absence  of  any  of  these  contrivances. 
Dubois  recommends  for  this  purpose  a  strong  2)air  of  lilunt  scissors. 
The  neck  is  brought  as  low  as  possible  l)y  traction  on  the  prolapsed  arm, 
and  the  blades  of  the  scissors  guided  carefully  up  to  it.  By  a  series  of 
cautious  snipping  movements  it  is  then  completely  divided  from  below 
upward.  This,  if  the  neck  be  readily  within  reach,  can  generally  be 
effected  without  any  particular  difficulty.  Dr.  Kidd  of  Dublin,^  who 
strongly  advocates  this  operation,  reconmiends  that  an  ordinary  male 
elastic  catheter,  strongly  curved  and  mounted  on  a  firm  stilette,  or,  still 
better,  on  a  uterine  sound,  should  be  passed  round  the  neck.  Previous 
to  introduction  a  cord  should  be  attached  to  the  extremity  of  the  cath- 
eter, which  is  left  round  the  neck  when  it  is  \^'ithdrawn.  By  means  of 
this  cord  a  strong  piece  of  whipcord  or  the  wire  of  an  ecraseur  can  easily 
be  drawn  round  the  neck  and  used  for  dividing  it.  The  former,  to  pro- 
tect the  maternal  structures,  may  be  \^'orked  through  a  speculum,  and 
by  a  series  of  lateral  movements  the  neck  is  easily  severed.  The  ecra- 
seur, however,  offers  special  advantage,  since  it  entirely  does  a^ay  with 
any  risk  of  injuring  the  mother. 

Withdraiml  of  the  Body  and,  Delivery  of  the  Head. — After  the  neck 
is  divided  the  remainder  of  the  operation  is  easy.  The  body  is  v^ith- 
drawn  without  difficulty  by  the  arm,  and  we  then  proceed  to  deliver 
the  head.  By  abdoniinal  pressure  tliis,  in  mqst_  eases^  can__be  j3ushed 
down  into  the  peTvis,  so  as.t£>  come  easily  witiiin, reach  of  jhe  c^^ 
trib^  wliicli  is  by  far  tlie  best  instrument  for  extraction.  PrcHmijiary 
perforation  is  not  necessary,  since  the  brain  can  escape  through  the  se\— 

^Dublin  Quart.  Jouni.,  May,  1871. 


CESAREAN  SECTION.  511 

ered  vertebral  canal.  The  secret  of  doing  this  easily  is  to  fix  and  press 
down  the  head  sufficiently  from  above,  otherwise  it  would  slip  away 
from  the  grasp  of  the  instrument.  The  perforator  and  craniotomy  for- 
ceps may  be  used  if  the  cephalotribe  be  not  at  hand.  Perforation  is, 
however,  by  no  means  always  easy,  on  account  of  the  mobility  of  the 
head.  After  it  is  accomplished  one  blade  of  the  craniotomy  forceps  is 
passed  within  the  skull,  the  other  externally,  and  the  head  slowly  drawn 
down. 

Evisceration. — The  alternative  operation  of  evisceratioii  is  a  mu£.h 
more_troublesome  and  tedious,  j^i'ocedure,  ^id  should  only  be  used  when 
tlie^neck  is  inaccessible.  The  first  step  is  to  perforate  the  thorax  at  its 
most  depending  part,  and  to  make  as  wide  an  opening  into  it  as  possible 
ii^order  to  gain  access  to  its  ci  >utents.  Through  this  the  thoracic  viscera 
arejrenioved  piecemeal,  being  first  broken  up  as  much  as  possible  by  the 
perforator,  and  then,  the  diaphragm  being  penetrated,  those  in  the  abdo- 
men. The  object  is  to  allow  the  body  to  collapse  and  the  pelvic  extrem- 
ities to  descend,  as  in  spontaneous  evolution.  This  can  be  much  facili- 
tated by  dividing  the  spinal  column  with  a  strong  pair  of  scissors  intro- 
duced into  the  opening  made  in  the  thorax,  so  that  the  body  may  be 
doubled  up  as  on  a  hinge.  Here  the  crotchet  may  find  a  useful  appli- 
cation, for  it  can  be  passed  through  the  abdominal  cavity  and  fixed  on 
some  point  in  the  interior  of  the  child's  pelvis,  and  thus  strong  traction 
can  be  made  without  any  risk  of  injury  to  the  mother.  It  can  be  readily 
understood  that  this  process  is  so  lengthy  and  difficult  as  to  render  it 
probably  the  most  trying  of  obstetric  operations ;  it  is^certainlj  inferior 
in  every  respect  to„ decapitation,  and  is  only  to  be  resorted  to  when  tKat 
is  impractieable. 

[The  Csesarean  operation  has  been  performed  in  the  United  States  in 
11  cases  of  impaction  of  the  foetus  in  a  transverse  position,  because  of 
the  great  difficulty  of  accomplishing  either  decapitation  or  evisceration, 
with  a  saving  of  7  women.     The  4  deaths  were  from  exhaustion. — Ed.] 


CHAPTER   VI. 

THE  C^SAEEAN  SECTION;  PORRO'S  OPERATION;  SYMPHYSEOTOMY. 

Ilidory  of  the  Ccesarean  Section. — The  Csesarean  section  has  perhaps 
given  rise  to  more  discussion  than  any  other  subject  connected  with  mid- 
wifijry,  and  there  is  yet  much  difference  of  opinion  as  to  the  limits  of, 
and  indications  for,  the  operation.  The  period  at  wliich  the  Cajsarean 
sciction  was  first  resorted  to  is  not  known  with  accuracy.  It  seems  to 
hav(;  been  practised  by  the  Greeks  after  the  dcatli  of  the  mother,  and 
IMiny  mentions  tliat  S('i[)io  AlVicanus  and  Manlius  Avere  born  in  this 
way.  The  nanu;  of  Cyicsar  is  said  to  have  been  given  to  chihh'cn  so 
extracted,  and  afterward  to  have  been  assumed  as  a  family  patronymic. 


512  OBSTETRIC  OPERATIONS. 

These  children  were  dedicated  to  Apollo ;  whence  arose  the  practice  of 
things  sacred  to  that  god  being  taken  nnder  the  special  protection  of  the 
family  of  the  Csesars.  Many  celebrities  have  been  supposed  to  owe  their 
lives  to  the  operation  ;  among  the  rest,  ^scnlapius,  Julius  Caesar,  and 
our  own  Edward  VI.  Regarding  the  two  latter,  there  is  conclusive  proof 
that  the  tradition  is  without  foundation.  There  is  no  doubt  that  the  ope- 
ration was  constantly  practised  on  women  who  had  died  at  an  advanced 
period  of  pregnancy,  and  indeed  it  has  at  various  times  been  enforced 
by  law.  Thus,  among  the  Romans  it  was  decreed  by  Numa  that  no 
pregnant  woman  should  be  buried  until  the  foetus  had  been  removed  by 
abdominal  section.  The  Italian  laws  also  made  it  necessary,  and  the 
operation  has  always  received  the  strong  support  of  the  Roman  Church. 
So  lately  as  the  middle  of  the  eighteenth  century  the  king  of  Sicily  sen- 
tenced to  death  a  physician  who  had  neglected  to  practise  it.  The  first 
authentic  case  in  which  the  operation  was  performed  on  a  living  woman 
occurred  in  1491.  It  was  afterward  practised  by  Nufer  in  1500;  and 
in  1581,  Rousset  published  a  work  on  the  subject  in  which  a  number 
of  successful  cases  were  related.  In  English  works  of  that  time  it  is 
not  alluded  to,  although  it  ^^^as  undoubtedly  performed  on  the  Continent, 
and  to  such  an  extent  that  its  abuse  became  almost  proverbial.  We  have 
evidence  in  Shakespeare,  however,  that  the  operation  was  familiarly 
known  in  this  country,  since  he  tells  us  that 

"  Macduff  was  from  his  mother's  womb 
Untimely  rij^ped."  \}'\ 

Pare  and  Guillemeau,  amongst  the  writers  of  the  period,  were  noted  for 
their  hostility  to  the  operation,  while  others  equally  strongly  upheld  it. 

In  this  country  it  has  scarcely  ever  been  performed  in  a  manner  which 
offers  even  the  faintest  hope  of  success.  It  has  been  looked  upon  as 
almost  necessarily  fatal  to  the  mother,  and  it  has  therefore  been  delayed 
until  the  patient  has  arrived  at  the  utmost  stage  of  exhaustion.  For 
example,  in  looking  over  the  records  of  British  cases  it  is  no  unconnnon 
thing  to  find  that  the  Csesarean  section  was  resorted  to  two,  three,  or 
even  six  days  after  labor  had  begun,  and  when  the  patient  was  almost 
moribund.  With  rare  exceptions  within  the  last  few  years  the  opera- 
tion has  been  performed  in  what  may  be  called  a  haphazard  way.  In 
many  cases  long  and  fruitless  attempts  at  delivery  by  craniotomy  had 
already  been  made,  so  that  the  passages  had  been  subjected  to  nmch  con- 
tusion and  violence.  Little  or  no  attempt  has  been  made  to  obviate  the 
well-known  risks  of  abdominal  operations  ;  no  care  has  been  taken  to 
prevent  blood  and  other  fluids  finding  their  way  into  the  peritoneal  cav- 
ity, and  no  means  have  been  adopted  subsequently  to  remove  them.  It 
is  therefore  not  so  much  a  matter  of  surprise  that  the  mortality  has  been 
so  great,  but  rather  that  any  cases  have  recovered. 

From  what  we  know  of  the  history  of  ovariotomy,  its  early  fitality, 
and  the  extreme  and  even  apparently  exaggerated  precautions  which  are 
essential  to  its  success,  it  is  fair  to  conclude  that  if  the  Csesarean  section 

[^  To  my  mind,  this  refers  to  what  had  often  taken  place  in  ancient  wars,  where 
women  were  ripped  open  by  soldiers  with  a  sword.  The  expression  untimely  does  not 
indicate  that  the  foetus  had  come  to  maturity  or  that  the  woman  was  in  labor. — Ed.] 


CESAREAN  SECTION.  513 

were  performed,  as  it  is  to  be  hoped  it  always  will  be  in  future,  with  the 
same  careful  attention  to  minute  details  as  ovariotomy,  the  results  would 
not  be  so  disastrous.  Making  every  allowance  for  these  facts,  it  must 
be  admitted  that  the  Csesarean  section  is  necessarily  almost  a  forlorn 
hope ;  and  in  making  these  observations  I  have  no  intention  of  contest- 
ing the  well-established  rule  of  British  practice,  that  it  is  not  admissible 
as  an  operation  of  election,  and  must  only  be  resorted  to  when  delivery 
per  vias  naturales  is  impossible. 

Statistical  Returns  not  Reliable. — The  mortality,  as  given  in  statistical 
returns  from  various  sources,  differs  so  greatly  as  to  make  them  but  lit- 
tle reliable.  Radford  has  tabulated  the  operations  performed  in  this 
country  up  to  1868,  and  the  list  has  been  completed  by  Harris^  up  to 
1879. f]  The  cases  amount  to  118  in  all,  of  which  22  were  successful, 
or  rather  more  than  18  per  cent.  JVIichaelis  and  Kayser  found  that  out 
of  258  and  338  operations,  54  and  64  per  cent,  respectively  were  fatal. 
These  include  operations  performed  under  all  sorts  of  conditions,  even 
when  the  patient  was  almost  moribund  ;  and  until  we  are  in  possession 
of  a  sufficient  number  of  cases  performed  under  conditions  showing  that 
the  result  is  obviously  due  to  tlie  operation,  in  which  it  was  undertaken 
at  an  early  period  of  labor  and  performed  with  a  reasonable  amount  of 
care,  it  is  obviously  impossible  to  arrive  at  any  reliable  conclusions  as  to 
the  mortality  of  the  operation.  That  it  is  necessarily  hopeless  is  cer- 
tainly not  the  case,  and  we  know  that  on  the  Continent,  where  it  is 
resorted  to  much  oftener  and  earlier  in  labor  than  in  this  country,  there 
are  authentic  cases  in  which  it  has  been  performed  twice,  thrice,  and 
even,  in  one  instance,  four  times,  on  the  same  patient.  Kayser  thinks 
that  a  second  operation  on  the  same  patient  affords  a  better  prognosis 
than  a  first,  probably  because  peritoneal  adhesions  resulting  from  the 
first  operation  have  shut  off  the  general  abdominal  cavity  from  the 
uterine  wound ;  and  he  believes  that  in  second  operations  the  mortality 
is  not  more  than  29  per  cent. 

The  Ccesarean  Section  in  America. — The  Csesarean  section  has  been 
much  more  successful  in  America  than  in  Great  Britain.  Dr.  Harris 
of  Philadelphia,  who  has  paid  much  attention  to  the  subject,  has  col- 
lected 134  cases  occurring  in  the  United  States,  of  which  53  were  suc- 
cessful as  regards  the  mother.  These  favorable  results  he  refers  partly 
to  the  fact  that  none  of  the  American  cases  were  the  subjects  of  mollities 
ossium,  rachitic  patients  forming  one-half  of  the  entire  number,  and  partly 
to  the  prevalence  of  habits  of  beer-  and  gin-drinking  in  this  country. 
He  also  gives  some  interesting  facts  showing  how  remarkably  the  mor- 
tality of  the  operation  is  lessened  when  it  is  performed  soon  and  the 
patient  is  not  exhausted  by  long  and  fruitless  labor.  Out  of  28  selected 
cases  of  this  kind,  21,  or  75  per  cent.,  were  successful.  [23  children 
were  delivered  alive,  and  19  saved. — Ed.] 

\_Ijdait  Ccesarean  Statistics  of  America. — For  some  years  we  have 

*  "Tlie  Cfesarean  Operation  in  the  United  Kingdom,"  Brit.  Med.  Journ.,  April  3, 
1880. 

['  The  late  Dr.  Radford  in  1880  tabulated  the  British  operations  to  May,  1879,  and 
presented  \'4'2  cases,  failing  to  notice  4,  1  of  which  recovered.  To  these  1  add  2  of  a 
later  date,  both  of  which  were  .saved,  making  in  all  138  cases,  w'th  26  recoveries. — Ed.] 


514  OBSTETRIC  OPERATIONS. 

been  very  decidedly  retrograding  in  our  proportion  of  cures  to  deaths 
and  of  timely  to  late  operations,  and  have  been  gradually  increasing  the 
percentage  of  deaths  in  the  whole  record.  Ten  years  ago,  when  we  had 
had  101  operations,  we  counted  45  women  saved,  or  a  fraction  below  45 
per  cent.  In  the  ten  years  we  have  added  33  cases,  with  25  women  and 
19  children  lost,  thereby  reducing  the  number  of  cures  below  40  per 
cent.  Worse  still  than  this,  the  operations  of  the  past  ten  months  in 
the  United  States  (April  1,  1884,  to  Feb.,  1885),  number  6,  and  all  of 
the  women  and  children  were  lost.  But  2  of  these  last  operations  have 
yet  been  reported  in  journals,  but  all  are  promised  for  publication.  Of 
the  33  operations  referred  to,  24  were  performed  upon  cases  regarded  as 
in  an  unfavorable  condition,  and  only  8  were  operated  upon  within  the 
first  twenty-foiu'  hours  of  labor.  It  is  not,  then,  to  be  wondered  at  that 
75  per  cent,  of  the  women  perished.  It  is  folly  in  an  accoucheur  to  expect 
a  surgeon  to  save  his  patient  when  broken  clown  and  exhausted  by  the 
length  of  her  labor. 

We  have  had  134  Cesarean  operations  in  the  United  States,  and  the 
addition  made  by  Mexico  and  the  West  Indies  increases  the  number  by 
9.  Of  the  134,  there  were  saved  53  women,  and  7  of  the  9,  making, 
in  all,  143  operations,  with  60  women  saved.  Of  the  134  cases  in  the 
United  States,  26  were  dwarfs,  ranging  in  height  from  3  feet  to  4  feet  8 
inches,  one-half  being  from  3  to  4  feet ;  and  of  these  26  but  7  were 
saved.  The  shortest  women  to  recover  were  respectively  3  feet  9  inches, 
3  feet  11^  inches,  and  4  feet.  Dwarfs  should  not  be  allowed  to  continue 
in  labor  more  than  from  two  to  four  hours,  as  they  rapidly  become 
exhausted,  and  are  apt  to  die  of  shock,  exhaustion,  or  peritonitis.  One 
dwarf,  operated  upon  and  saved  after  a  labor  of  two  hours,  was  already 
showing  the  evidences  of  exhaustion.  By  acting  very  promptly  the 
labor  only  having  lasted  1^  hours,  a  physician  of  Brest,  France,  was 
successful  in  saving  a  woman  only  35  inches  in  height,  with  her  child, 
a  few  years  ago.  He  appeared  to  know  the  value  of  time  to  such  a 
patient,  and,  when  called  in,  rapidly  made  his  arrangements  for  using 
the  knife.  The  term  "  early  "  is  a  relative  one,  and  what  might  be  such 
as  a  measure  of  time  in  one  case  would  not  be  in  another.  '^  Timely  "  has 
no  measure  in  hours,  but  relates  more  to  the  strength  and  condition  of 
the  patient.  If  the  strength,  pulse,  and  morale  of  the  woman  indi- 
cate a  favorable  condition,  and  she  has  not  had  active  labor  beyond 
a  few  hours,  she  will  in  the  majority  of  instances  in  our  country 
recover. — Ed.] 

Results  to  the  Child. — The  mortality  of  the  children  likewise  cannot 
be  ascertained  from  statistical  returns,  since  in  the  large  majority  of 
cases  in  which  dead  children  were  extracted  the  result  had  nothing  to  do 
with  the  operation.  Indeed,  there  is  nothing  in  the  operation  itself 
which  can  reasonably  be  supposed  to  affect  the  child.  If,  therefore,  the 
child  be  alive  when  the  operation  is  commenced,  there  is  every  probabil- 
ity of  its  being  extractecl  alive ;  and  Radford's  conclusion,  that  "  the 
risk  to  infants  in  Ceesarean  births  is  not  much  greater  than  that  which 
is  contingent  on  natural  labor,  provided  correct  principles  of  practice  are 
adopted,"  probably  very  nearly  represents  the  truth. 

Causes  Requiring  the  Operation. — The^  Caesarean  section  is  required 


CESAREAN  SECTION.  515 

when  there  is  such  defective  proportion  between  the  child  and  the 
maternal  passages  that  even  a  mutilated  fcetus  cannot  be  extracted. 
This  in  by  far  the  greatest  number  of  cases  is_  due  to  deformity  of  the 
pelvis  arising  from  rickets  or  mollities  ossimn.  The  latter  may  occur 
in  a  patient  who  has  been  previously  healthy  and  who  has  given  birth 
to  living  children.  It  is  a  more  common  cause  of  the  extreme  varieties 
of  deformity  than  rickets,  and  out  of  77  British  cases,  tabulated  by  Rad- 
ford, in  43  the  deformity  was  produced  by  osteo-malacia  and  in  14  only 
by  rickets.[^]  In^certain  cases  the  pelvis  itself  may  be  of  normal  size, 
but  has  its  cavity  obstructed  by  a  solid  tumor  of  the  ovary_,  of  the  uterus 
itself^  or  one  growing  from  the  pelvic  wall.  The  obstruction  may  also 
dejDend  on  morbid  conditions  of  the  maternal  soft  X3arts,  of  which  the 
most  common  is  advanced  malignant  disease  of  the  cervix.  Other  con- 
ditions may,  however,  render  the  operation  essential.  Thus,  Dr.  New- 
man^ records  a  case  in  which  he  performed  it  for  insurmountable  resist- 
ance and  obstruction  of  the  cervix,  which  was  believed  at  the  time  to  be 
caused  by  malignant  disease.  The  patient  recovered,  and  was  subse- 
quently delivered  naturally  and  without  anything  abnormal  being  made 
out.  This  renders  it  probable  that  the  disease  was  not  malignant,  and 
it  may  possibly  have  been  an  extensive  inflammatory  exudation  into  the 
tissues  of  the  cervix,  subsequently  absorbed.  I  myself  was  present  at  a 
Ceesarean  section  performed  in  Calcutta  in  the  year  1857  wlien  the  pel- 
vis^ was  so  uniformly  blocked  up  with  exudation,  probably  due  to  exten- 
sive pelvic  cellulitis  or  hsematocele,  that  the  operation  was  essential. 

Limits  of  Obstruction  Justifying  the  Operation. — Different  accoucheurs 
have  fixed  on  various  limits  for  the  operation.  Most  British  authorities 
are  of  opinion  that  it  need  not  be  resorted  to  if  the  smallest  diameter  of 
the  pelvis  exceed  \^  inches.^  This  question  has  already  l)een  considered 
in  discussing  craniotomy,  and  it  has  been  shown  that  a  mutilated  foetus 
may  be  drawn  through  a  pelvis  of  1-|  inches  antero-posterior  diameter, 
provided  there  be  a  space  of  3  inches  in  the  transverse  diameter.  If 
sufficient  space  for  using  the  necessary  instruments  do  not  exist,  the 
Cesarean  section  may  be  required  even  when  there  is  a  larger  antero- 
posterior diameter  than  1|-  inches.  This  is  especially  likely  to  occur 
when  we  have  to  do  with  deformity  arising  from  mollities  ossium,  in 
which  the  obstruction  is  in  the  sides  and  outlet  of  the  pelvis,  the  true 
conjugate  being  sometimes  even  elongated.  On  the  Contineiit  the 
Qesarean  section  is  constantly  j^ractised,  as  an  operation  of  election, 
when  the  smallest  diameter  measures  from  2  to  2\  inches  ;  and  when 
tlic  child  is  known  to  be  alive  some  foreign  authors  recommend  it  Avhen 
there  is  a.s  much  as  3  inches  in  the  antero-posterior  diameter.  In  this 
country,  where  the  life  of  the  child  is  most  properly  considered  of  sec- 
ondary importance  to  the  safety  of  the  mother,  we  cannot  fix  one  limit 
for  the  oj)eration  when  the  child  is  living  and  another  when  it  is  dead. 
Kor,  I  think,  can  we  admit  the  desire  of  the  mother  to  run  the  risk, 

['  I  must  again  fill  np  the  record  of  Dr.  Radford.  Of  his  132  cases,  56  were  the  subjects 
of  tnolliticH  ossium,  and  in  81  the  deformity  of  tlie  pelvis  was  attributed  to  rickets:  14 
cases  were  the  subjects  of  cancer  and  10  of  tumors. — J'^D.] 

'^  Ohnt.  Trann.,  vol.  vii.  ji.  343. 

•■'  In  Dr.  Parry's  table  of  70  craniotomies  there  are  34  cases  of  2  to  2^  inches  conju- 
gate. 


516  OBSTETRIC  OPERATIONS. 

rather  than  sacrifice  the  child,  as  a  justification  of  the  operation,  although 
tliis  is  laid  down  as  an  indication  by  Scliroeder.^  Great  a.s  are  the  dan- 
2;ers  attending  craniotomy  in  extreme  deformity^  tlTerc  can  be  no  doubt 
tliat  we  must  perform  it  whenever  it  is  practicable,  and  only  resort  to 
the  Csesarean  section  when  no  other  means  of  delivery  are  possible. 

For  this  reason  I  think  it  unnecessary  to  discuss  the  question  Avhether 
we  are  justified  in  destroying  the  foetus  in  several  successive  pregnancies 
when  the  mother  knows  that  it  is  impossible  for  her  to  give  birth  to  a 
living  child.  Denman  was  the  first  to  question  the  advisability  of 
repeating  craniotomy  on  the  same  patient.  Amongst  modern  authors, 
Radford  takes  the  most  decided  view  on  this  point,  and  distinctly 
teaches  that  even  when  delivery  by  craniotomy  is  possible,  it  "  can  be 
justified  on  no  principle,  and  is  only  sanctioned  by  the  dogma  of  the 
schools  or  by  usage,"  and  that,  therefore,  the  Cesarean  section  should 
be  performed  with  the  view  of  saving  the  child.  Doubtless,  much  can 
be  said  from  this  point  of  view,  but,  nevertheless,  he  would  be  a  bold 
man  wdio  would  deliberately  elect  to  perform  the  Cesarean  section  on 
such  grounds.^  It  is  to  be  hoped,  however,  that  in  these  days  the 
induction  of  premature  labor  or  abortion  would  always  spare  us  the 
necessity  of  deciding  so  delicate  a  point. 

Post-mortem  Ccesarean  O'peration. — The  C9esarean  section  may  also 
be  required  in  cases  in  which  death  has  occurred  during  pregnancy  or 
labor.  This  was  the  indication  for  which  it  was  first  employed,  and  it 
has  constantly  been  performed  when  a  pregnant  wx)man  has  died  at  an 
advanced  period  of  utero-gestation.  There  is  no  doubt  that  a  prompt 
extraction  of  the  child  under  these  circumstances  has  frequently  been 
the  means  of  saving  its  life,  but  by  no  means  so  often  as  is  generally 
supposed.  Thus,  Schwartz^  showed  that  out  of  107  cases  not  one  living 
child  was  extracted.  Duer*  has  written  an  interesting  paper  on  this 
subject  in  which  he  has  tabulated  55  cases  of  post-mortem  Caesarean 
sections.  In  40  a  living  child  was  extracted,  the  time  elapsing  after  the 
death  of  the  mother  being  as  follows :  "  Between  1  and  5  minutes,  in- 
cluding '  immediately'  and  '  in  a  few  minutes,'  there  were  21  cases ; 
between  5  and  10  minutes,  none;  between  10  and  15  minutes,  13  cases; 
between  15  and  23  minutes,  2  cases;  after  1  hour,  2  cases;  and  after  2 
hours,  2  cases."  In  those  extracted,  however,  after  the  lapse  of  an  hour 
the  children  did  not  ultimately  survive,  and  the  cases  themselves  seem 
open  to  some  doubt. 

Want  of  Success  in  Post-mortem  Operation. — The  reason  that  the  want 
of  success  has  been  so  great  is  doubtless  the  delay  that  must  necessarily 
occur  before  the  operation  is  resorted  to,  for,  independently  of  the  fact 
that  the  practitioner  is  seldom  at  hand  at  the  moment  of  death,  the  very 
time  necessary  to  assure  ourselves  that  life  is  actually  extinct  will  gen- 

^  Mrnmnl  of  Midwifery,  p.  202. 

"  Tliis  was  done  twice  successfully  by  Prof.  "William  Gibson  in  tbe  case  of  Mrs. 
Eeybold  of  Philadelphia  in  1835  and  1837,  after  she  had  twice  been  delivered  by 
craniotomy  vmder  Pi'of.  Charles  D.  Meigs,  who  declined  destroying  any  more  children 
for  her.  Mrs.  R.  still  lives  at  the  age  of  seventy-five,  and  the  daughter  likewise,  with 
her  four  children.     The  son  died  at  43,  leaving  two  children. — -PIarris. 

3  Momit.f.  Gebnrt.  suppl.  vol.,  1861,  p.  121. 

*■  "Post-mortem  Delivery,"  Am.  Journ.  of  ObM.,  Jan.,  1879. 


CESAREAN  SECTION.  517 

erally  be  sufficient  to  cause  the  death  of  the  foetus.  Considering  the 
intimate  relations  between  the  mother  and  child,  we  can  scarcely  expect 
vitality  to  remain  in  the  latter  more  than  a  quarter,  or  at  the  outside 
half  an  hour,  after  it  has  ceased  in  the  former.  The  recorded  instances 
in  which  a  living  child  was  extracted  ten,  twelve,  and  even  forty  hours 
after  death  were  most  probably  cases  in  which  the  mother  fell  into  a 
prolonged  trance  or  swoon,  during  the  continuance  of  which  the  child 
must  have  been  removed.  A  few  authentic  cases,  however,  are  known 
in  which  there  can  be  no  reasonable  doubt  that  the  operation  was  per- 
formed successfully  several  hours  after  the  mother  was  actually  dead. 

Since,  then,  there  is  a  chance,  however  slight,  of  saving  the  child's 
life,  we  are  bound  to  perform  the  operation,  even  when  so  much  time 
has  elapsed  as  to  render  the  chances  of  success  extremely  small.  It 
might  be  considered  almost  superfluous  to  insist  on  the  necessity  of 
assuring  ourselves  of  the  mother's  death  before  commencing  the  neces- 
sary incisions ;  but,  unfortunately,  numerous  instances  are  known  in 
which  mistakes  in  diagnosis  have  been  made,  and  in  which  the  first 
steps  of  the  operation  have  shown  that  the  mother  was  still  alive.  The 
operation  should  therefore  always  be  performed  \vith  the  same  care  and 
caution  as  if  the  mother  were  living.  If  death  have  occurred  during 
labor,  some  have  advised  version  as  a  preferable  alternative.  This  can 
only  be  resorted  to  with  any  hope  of  success  if  the  passages  be  in  a  con- 
dition to  admit  of  delivery  with  rapidity ;  otherwise  the  delay  occasioned 
by  dilatation,  even  when  forcibly  accomplished,  and  the  drawing  of  the 
child  through  the  pelvis,  will  be  almost  necessarily  fatal.  The  only 
argument  in  favor  of  version  is,  that  it  is  less  painful  to  the  friends ; 
and,  if  they  manifest  a  decided  objection  to  the  Csesarean  section,  there 
can  be  no  reason  why  an  attempt  to  save  the  child  in  this  way  should 
not  be  made. 

Causes  of  Death  after  Ccesarean  Section. — The  causes  of  death  after 
the  Cesarean  section  may,  speaking  generally,  be  classed  under  four 
principal  heads:  hemorrhage,  peritonitij  and  metritis,  shock,_ septicaemia, 
and  exhaustion  from  long  delay.  These  are  pretty  much  the  same  as 
those  following  ovariotomy,  and  the  resemblance  between  the  two  opera- 
tions is  so  great  that  modern  experience  as  to  the  best  mode  of  perform- 
ing ovariotomy,  as  well  as  regards  the  after-treatment,  may  be  taken  as 
a  guide  in  the  management  of  cases  of  Csesarean  section. 

Hemorrhage  is  Frequent,  although  Seldom  Fatal. — Hemorrhage  to  an 
alarming  extent  is  a  frequent  complication,  though  seldom  the  cause  of 
death.  Thus,  out  of  88  operations  the  particulars  of  which  have  been 
carefully  noted,  severe  hemorrhage  occurred  in  14,  6  of  which  terminated 
successfully,  and  in  4  only  could  the  fatal  result  be  ascribed  to  the  loss 
of  blood.  In  1  of  these  the  source  of  the  hemorrhage  is  not  mentioned, 
in  another  it  came  from  the  wound  in  the  abdominal  wall,  and  in  the 
other  2  from  the  utcriiK!  incision  Ixsing  made  directly  over  the  j^lacenta. 
In  neitlier  of  the  two  ]att(,'r  was  the  loss  of  blood  immediately  fiital,  for 
it  was  checked  l)y  uterine  contraction,  and  only  recurred  after  many 
hours  had  elapsed.  TIk;  divided  uterine  sinuses  and  the  open  mouths 
of  tlie  vessels  at  the  placental  site  are  the  most  common  sources  of  hem- 
onhage. 


518  OBSTETRIC  OPERATIONS. 

Means  of  Avoiding  the  Risk. — Much  may  be  done  to  diminish  the 
risk  of  bleeding,  but  even  with  every  precaution  it  must  be  a  source  of 
danger.  Hemorrhage  from  the  abdominal  wall  may  be  best  prevented 
by  making  the  incision  as  nearly  as  possible  in  the  line  of  the  linea  alba, 
so  as  not  to  wound  the  epigastric  arteries,  and  by  controlling  bleeding 
by  pressure-forceps  as  we  proceed,  as  is  done  in  ovariotomy.  The  j)rin- 
cipal  loss  of  blood  wdll  be  met  with  in  dividing  the  uterus ;  and  this 
will  be  the  greatest  wdien  the  incision  is  near  or  over  the  placental  site, 
^^•here  the  largest  vessels  are  met  with.  We  are  recommended  to  ascer- 
tain the  position  of  the  placenta  by  auscultation,  and  thus,  if  possible,  to 
avoid  opening  the  uterus  near  its  insertion.  But  even  if  w^e  admit  the 
placental  souffle  to  be  a  guide  to  its  situation  if  the  placenta  be  attached 
to  the  anterior  walls  of  the  uterus,  a  knowledge  of  its  position  would  not 
always  enable  us  to  avoid  opening  the  uterus  in  its  immediate  vicinity. 
We  must,  in  the  event  of  its  lying  under  the  incision,  rather  hope  to 
control  the  hemorrhage  by  removing  it  at  once  from  its  attachments  and 
rapidly  emptying  the  uterus.  When  the  child  has  been  removed  there 
may  be  a  large  escape  of  blood,  but  this  will  generally  be  stopped  by 
the  contraction  of  the  uterus  in  the  same  manner  as  after  natural  labor. 
Should  contraction  not  take  place,  the  uterus  may  be  firmly  grasped  for 
the  purpose  of  exciting  it.  This  j^lan  is  advocated  by  Winckel,  who 
had  a  large  experience  in  the  operation,  and  by  using  free  compression 
in  this  way,  and  making  a  point  of  not  closing  the  w^ound  until  the 
uterus  is  firmly  contracted,  he  has  never  met  wdth  any  inconvenience 
from  hemorrhage.  If  bleeding  continue,  styptic  applications  may  be 
used,  as  in  a  case  reported  by  Hicks,  who  was  obliged  to  swab  out  the 
uterine  cavity  with  a  solution  of  perchloride  of  iron. 

Peritonitis  and  Metritis  are  Frequent  Causes  of  Death. — Among  the 
most  frequent  causes  of  death  are  peritonitis  and  metritis.  Kayser 
attributes  the  fatal  result  to  them  in  77  out  of  123  unsuccessful  cases. 
The  mere  division  of  the  peritoneum  will  not  account  for  the  frequency 
of  this  complication,  since  its  occurrence  is  considerably  more  frequent 
than  after  ovariotomy,  in  which  the  injury  to  the  peritoneum  is  quite  as 
great ;  and  indeed  greater,  if  we  take  into  account  the  adhesions  which 
have  to  be  divided  or  torn  in  that  operation. 

Degeneration  of  the  Uterine  Fibres  supposed  to  be  Unfavorable  to 
Repair, — The  division  of  the  uterus  must  be  regarded  as  one  source 
of  this  danger.  Dr.  AVest  lays  great  stress  on  its  unfavorable  condition 
after  delivery  for  reparative  action.  He  believes  that  the  process  of 
involution  or  fatty  degeneration  which  commences  in  the  muscular  fibres 
previous  to  delivery  renders  them  peculiarly  unfitted  to  cicatrize;  and 
he  points  out  that  on  post-mortem  examination  the  edges  of  the  incision 
have  been  found  dry,  of  unhealthy  color,  gaping,  and  showing  no  tend- 
ency to  heal.  On  this  account,  Hicks  and  others  have  operated  ten 
days  or  more  before  the  full  period  of  labor,  in  the  hope  that  the  risk 
from  this  source  might  be  avoided.  It  is  by  no  means  certain,  however, 
that  the  change  in  the  uterine  fibres  is  the  cause  of  the  wound  not  heal- 
ing, and  involution  will  commence  at  once  when  the  uterus  is  emptied 
even  if  the  full  period  of  pregnancy  have  not  arrived.  As  a  point  of 
ethics,  moreover,  it  is  questionable  if  we  are  justified  in  anticipating  the 


CESAREAN  SECTION.  519 

date  of  so  dangerous  an  operation,  even  by  a  few  weeks,  unless  the  bene- 
fit to  be  derived  is  very  decided  indeed. 

Escape  of  Lochia  and  other  Flidds  into  the  Peritoneal  Cavity. — One 
important  cause  of  peritonitis  is  the  escape  of  the  lochia  through  the 
uterine  incision  into  the  cavity  of  the  peritoneum,  which  there  decom- 
pose and  act  as  an  unfailing  source  of  irritation.  This  may  be  prevented, 
to  a  great  extent,  by  seeing  that  the  os  uteri  is  patulous,  so  as  to  afford 
a  channel  for  the  escape  of  discharges,  and  by  closing  the  uterine  wound 
by  sutures.  In  addition,  there  is  the  danger  arising  from  blood  and 
liquor  amnii  escaping  into  the  peritoneum  and  subsequently  decompos- 
ing. There  is  little  evidence  that  "  la  toilette  du  peritoine,"  on  which 
ovariotomists  now  lay  so  much  stress,  has  ever  been  particularly  attended 
to  in  Csesarean  operations. 

The  Unhealthy  Condition  of  the  Patient  is  tlie  Chief  Source  of  Dan- 
ger.— The  chief  predisposing  cause  of  these  inflammations,  however, 
must  be  looked  for  in  the  condition  of  the  patient,  just  as  asthenic 
inflammation  in  ovariotomy  is  most  frequently  met  with  in  those  whose 
general  health  is  broken  down  by  the  long  continuance  of  the  disease. 
We  are  fully  justified,  therefore,  in  assumhig  that  peritonitis  and  metri- 
tis will  be  more  likely  to  occur  after  the  Cesarean  section  when  that 
operation  has  been  unnecessarily  delayed  and  when  the  patient  is 
exhausted  by  a  protracted  labor.  In  proof  of  this  we  find  that  in  a 
large  proportion  of  the  cases  above  mentioned  peritonitis  occurred  when 
the  operation  was  performed  under  unfavorable  conditions. 

Septiccemia. — The  sources  of  septicsemia  are  abundantly  evident — not 
the  least,  probably,  being  absorption  by  the  open  vessels  in  the  uterine 
incision. 

Nervous  Shoch. — The  last  great  danger  is  general  shock  to  the  nervous 
system.  In  Kayser's  123  cases,  30  of  the  deaths  are  referred  to  this 
cause.  In  the  large  majority  of  these  the  patient  was  profoundly 
exhausted  before  the  operation  was  begun.  It  is  in  predisposing  to 
these  nervous  complications  that  we  should,  a  priori,  expect  that  vacil- 
lation and  delay  would  be  most  hurtful  ;  and  in  operating  when  the 
patient's  strength  is  still  unimpaired  we  afford  her  the  best  chance  of 
bearing  the  inevitable  shock  of  an  operation  of  such  magnitude. 

Secondary  Dangers. — In  addition  a  few  cases  have  been  lost  from 
accidental  complications,  which  are  liable  to  occur  after  any  serious 
operation,  and  which  do  not  necessarily  depend  on  the  nature  of  the 
procedure. 

Danger  to  Child  from  Portions  of  its  Body  being  Caught  by  the  Con- 
tracting Uterus. — There  is  only  one  source  of  danger  special  to  the  child 
which  is  worthy  of  attention.  As  the  infant  is  being  removed  from  the 
cavity  of  the  uterus  the  muscular  parietes  sometimes  contract  with  great 
ra[)i(lity  and  f  jrce,  so  as  to  seize  and  retain  some  part  of  its  body.  This 
occurred  in  two  of  Dr.  Iladford's  cases,  and  in  one  of  tlicm  it  is  stated 
that  "the  chihl  was  vigorously  alive  when  first  taken  hold  of,  but  from 
the  length  of  time  occupied  in  (ixtrac^ting  the  head  it  became  so  enfeel>led 
as  to  show  only  slight  signs  of  life,"  and  subsequently  all  attempts  at 
resuscitation  failed.  I  have  myself  seen  the  head  caught  in  this  way, 
and  so  forcibly  retained  that  a  second  incision  was  required  to  relciasc  it. 


520  OBSTETRIC  OPERATIONS. 

In  Dr.  Radford's  cases  the  placenta  happened  to  be  immediately  under 
the  incision,  and  he  attributes  the  inordinate  and  rapid  contraction  of 
the  uterus  to  its  premature  separation.  It  is  difficult  to  believe  that  this 
was  more  than  a  coincidence,  because  the  contraction  does  not  take  place 
until  the  greater  part  of  the  child's  body  has  been  withdrawn,  and 
because  numerous  cases  are  recorded  in  which  the  uterus  was  oj)ened 
directly  over  the  placenta,  or  in  which  it  was  lying  loose  and  detached, 
in  none  of  which  this  accident  occurred.  The  true  explanation  may, 
I  think,  be  found  in  the  varying  irritability  of  the  uterus  in  difi'erent 
cases. 

Irrespective  of  the  risk  of  portions  of  the  child  being  caught  and 
detained,  rapid  contraction  is  a  distinct  advantage,  since  the  danger  of 
hemorrhage  is  thereby  thus  diminished.  Serious  consequences  may  be 
best  avoided  by  removing,  when  practicable,  the  head  and  shoulders  of 
the  child  first,  or  by  employing  both  hands  in  extraction,  one  being 
placed  near  the  head,  the  other  seizing  the  feet.  Either  of  these  methods 
is  preferable  to  the  common  practice  of  laying  hold  of  the  part  that 
may  chance  to  lie  most  conveniently  near  the  line  of  incision.  If  this 
point  were  properly  attended  to,  although  the  detention  of  the  lower 
extremities  might  occasionally  occur,  the  life  of  the  child  would  not  be 
imperilled. 

Whenever  it  is  Possible  the  Patient  should  be  Prepared  for  the  Opera- 
tion.— The  preparation  of  the  patient  for  the  operation  should  seriously 
occupy  the  attention  of  the  practitioner ;  and  this  is  the  more  essential 
since  almost  all  patients  requiring  the  Csesarean  section  are  in  a 
wretchedly  debilitated  condition.  If  the  patient  be  not  seen  until  she  is 
actually  in  labor,  of  course  this  is  out  of  the  question.  But  this  will 
rarely  be  the  case,  since  the  deformed  condition  of  the  patient  must 
generally  have  attracted  attention.  Every  possible  means  should  be 
taken,  therefore,  when  practicable,  to  improve  the  general  health  by 
abundance  of  simple  and  nourishing  diet,  plenty  of  fresh  air,  and  suit- 
able tonics  (amongst  which  preparations  of  iron  should  occupy  a  promi- 
nent place),  while  the  state  of  the  secretions,  the  bowels,  skin,  and  kid- 
neys should  be  specially  attended  to.  Whenever  it  is  possible  a  large, 
airy  apartment  should  be  selected  for  the  operation,  which  should  never 
be  done  in  a  hospital  if  other  arrangements  be  practicable.  These 
details  may*  seem  trivial  and  unnecessary ;  but  to  ensure  success  in  ,so 
hazardous  an  nndertaking  no  care  can  be  considered  superfluous,  and 
probably  the  want  of  attention  to  such  points  has  had  much  to  do  with 
increasing  the  mortality. 

Question  of  Time  to  be  Selected  for  the  Operation. — The  question  arises 
whether  we  should  operate  before  labor  has  commenced.  By  selecting 
our  own  time,  as  some  have  advised,  we  certainly  have  the  advantage  of 
operating  under  the  most  favorable  conditions,  instead  of,  possibly,  hur- 
riedly. There  are,  however,  numerous  advantages  in  waiting  until  spon- 
taneous uterine  action  has  commenced  which  seem  to  me  to  more  than 
counterbalance  the  advantages  of  choosing  our  own  time.  Prominent 
among  these  is  the  partial  opening  of  the  os  uteri,  so  as  to  afford  a  chan- 
nel for  the  escape  of  the  lochia,  and  the  certainty  of  active  contraction 
of  the  uterus  to  arrest  hemorrhage.    Barnes  recommends  that  premature 


CESAREAN  SECTION.  521 

labor  should  be  first  induced,  and  then  the  operation  performed.  This 
seems  to  me  to  introduce  a  needless  element  of  complexity  ;  and,  besides, 
in  cases  of  great  deformity  it  is  by  no  means  always  easy  to  reach  the 
cervix  with  the  view  of  bringing  on  labor.  All  needful  arrangements 
should  be  made,  so  as  to  avoid  hurry  and  excitement  when  the  operation 
is  commenced,  and  we  may  then  wait  patiently  until  labor  has  fairly 
set  in. 

The  Administration  of  Anaesthetics. — The  operation  itself  is  simple. 
The  patient  should  be  placed  on  a  table  in  a  good  light,  and  with  the 
temperature  of  the  room  raised  to  about  65°.  Chloroform  has  so  fre- 
quently been  followed  by  severe  vomiting  that  it  is  probably  better  not 
to  administer  it.  For  the  same  reason  Mr.  Spencer  Wells  has  long  given 
up  using  it  in  ovariotomy,  and  finds  that  chloro-methyl  answers  admira- 
bly ;  ether  also  is  devoid  of  the  disadvantages  of  chloroform.  In  one 
or  two  cases  local  angesthesia  has  been  used  by  means  of  two  spray-pro- 
ducers acting  simultaneously ;  and  this  plan,  if  the  patient  have  sufficient 
fortitude  to  dispense  with  general  angesthesia,  has  the  further  advantage 
of  stimulating  the  uterus  to  powerful  contraction. 

To  ensure  as  great  a  measure  of  success  as  possible  the  operation 
should  be  performed  under  carbolic  spray  and  with  all  the  minute  pre- 
cautions used  in  ovariotomy. 

Description  of  the  Operation. — The  incision  should  be  made  as  much 
as  possible  in  the  line  of  the  linea  alba,  so  as  to  avoid  w^ounding  the 
epigastric  arteries.  On  account  of  the  cleformity  the  configuration  of 
the  abdomen  is  often  much  altered,  and  some  have  advised  that  the 
incision  should  be  made  oblique  or  transverse  and  on  the  most  promi- 
nent part  of  the  abdomen.  The  risk  of  hemorrhage  being  thus  much 
increased,  the  practice  is  not  to  be  recommended.  The  incision,  com- 
mencing a  little  above  the  umbilicus,  is  carried  down  for  about  three 
inches  below  it.  The  skin  and  muscular  fibres  are  carefully  divided, 
layer  by  layer,  until  the  shining  surface  of  the  peritoneum  is  reached, 
and  any  bleeding  vessels  should  be  secured  as  we  proceed.  A  small 
opening  is  now  made  in  the  peritoneum,  which  should  be  laid  open  along 
the  whole  length  of  the  incision  upon  two  fingers  of  the  left  hand  intro- 
duced as  a  guide.  Before  incising  the  uterus  an  assistant  should  care- 
fully support  it  in  a  proper  position,  and  push  it  forward  by  the  hands 
placed  on  either  side  of  the  incision,  so  as  to  bring  its  surface  into  apposi- 
tion with  the  external  wound  and  prevent  the  escape  of  the  intestines. 
If  we  have  reason  to  believe  that  the  placenta  is  situated  anteriorly,  we 
may  incise  the  uterus  on  one  or  other  side  ;  otherwise  the  line  of  incision 
should  1)0  as  nearly  as  possible  central. '  The  substance  of  the  uterus  is 
next  divided  until  the  membranes  are  reached,  which  are  punctured  and 
divided  in  the  same  way  as  the  peritoneum.  The  uterine  incision  should 
be  of  the  same  length  as  that  in  the  abdomen,  and  it  should  not  be 
ma(l(;  too  near  the  fundus  ;  fi)r  not  only  is  that  ])art  more  vascular  than 
th(!  body  of  the  uterus,  but  wounds  in  that  situation  are  more;  apt  to 
gape,  and  do  not  cicati'izc;  so  favorably.  Aft(!r  the  uterus  is  ojx'ucd.  Dr. 
Ludwig  Winckel  recommends  that  the  fingers  of  an  assistant  should  be 

['  See  Kehrer's  plan  of  incising  tlie  uterus  transversely  for  this  purpose,  on  page 
524. — \i\i.~\ 


522  OBSTETRIC  OPERATIONS. 

placed  in  the  two  terminal  angles  of  the  woundj  so  that  the  ends  of 
the  incision  may  be  hooked  up  and  brought  into  close  apposition  with 
the  abdominal  opening.  By  this  means  he  prevents  not  only  the  escape 
of  blood  and  liquor  amnii  into  the  cavity  of  the  peritoneum,  but  also 
the  protrusion  of  the  abdominal  viscera. 

Removal  of  the  Child. — The  child  should  now  be  carefully  removed, 
the  head  and  shoulders  being  taken  out  (if  possible)  first ;  the  placenta 
and  membranes  are  afterward  extracted.  Should  the  placenta  be  unfor- 
tunately found  immediately  under  the  incision,  a  considerable  loss  of 
blood  is  likely  to  take  place,  which  can  only  be  checked  by  removing  it 
from  its  attachments  and  concluding  the  operation  as  rapidly  as  possible. 

Importance  of  Securing  Uterine  Contraction. — As  soon  as  the  child 
and  the  secunclines  have  been  extracted  the  sooner  the  uterus  contracts 
the  better.  It  will  usually  do  so  of  itself,  but  should  it  remain  lax  and 
flabby,  it  should  be  pressed  and  stimulated  by  the  hand.  We  are  spe- 
cially warned  against  handling  the  utertis  by  Ramsbotham  and  others, 
but  there  seems  no  valid  reason  why  we  should  not  restrain  hemorrhage 
in  this  way,  as  after  a  natiu^al  labor.  The  intervention  of  the  abdominal 
parietes  in  their  lax  condition  after  delivery  can  make  very  little  differ- 
ence between  the  two  cases.  Ergotin  administered  hypodermically  will 
also  be  useful  in  promoting  efficient  contraction. 

Closure  of  the  Uterine  and  Abdomincd  Wounds. — The  advisability  of 
closing  the  uterine  wound  by  sutures  is  a  mooted  point.  [^]  The  balance 
of  evidence  is  certainly  in  favor  of  this  practice,  as  tending  to  prevent 
the  escape  of  the  lochia  into  the  peritoneal  cavity.  Interrupted  sutures 
of  silver  Mare  may  be  used  and  cut  short,  or,  as  successfully  practised  by 
Spencer  Wells,  a  continuous  silk  suture  may  be  applied,  one  end  being 
passed  through  the  os  into  the  vagina,  by  M^hich  it  is  subsequently  with- 
drawn. Sutures  of  ordinary  catgut  are  apt  to  yield,  and  are  therefore 
unreliable  ;  but  chromic  gut  or  some  of  the  antiseptic  guts  now  prepared 
may  doubtless  be  used  with  safety.  Before  closing  the  uterine  wound 
one  or  two  fingers  should  be  passed  through  the  cervix  to  ensure  its 
being  patulous.  A  free  escape  of  the  lochia  in  this  direction  is  of  great 
consequence,  and  Winckel  even  advises  the  placing  of  a  strip  of  lint 
soaked  in  oil  in  the  os,  so  as  to  keep  up  a  free  exit  for  the  discharge. 

The  Abdomincd  Wound  should  not  be  Closed  until  Hcmorrliage  has 
Ceased. — A  point  of  great  importance,  and  not  sitfficiently  insisted  on, 
is  the  advisability  of  not  closing  the  abdominal  wound  until  we  arc 
thoroughly  satisfied  that  hemorrhage  is  completely  stopped,  since  any 
escape  of  blood  into  the  peritoneum  would  very  materially  lessen  the 
chances  of  recovery.  In  a  successful  case  reported  by  Dr.  Newman^  the 
wound  was  not  closed  for  nearly  an  hour.  Before  doing  so  all  blood 
and  discharges  should  be  carefully  removed  from  the  peritoneal  cavity 

[^  Uterine  sutures  have  been  in  nse  in  the  United  States  since  .June,  1828,  but  there 
were  only  4  cases  thus  treated  from  1828  to  1868,  since  which  time  there  have  been 
27,  making  31  in  alb  Of  these,  12  were  sutured  witli  silver  wire,  and  6  recovered;  15 
with  silk,  and  4  were  saved  ;  1  with  fine  hemp,  recovered  ;  2  with  catgut,  lost ;  and  1 
with  an  unnamed  material,  lost.  Of  the  28  early  operations  in  the  list  of  the  United 
States,  but  6  were  sutured,  saving  3 ;  and  of  the  balance,  22,  there  were  18  that  recov- 
ered.— Ed.] 

^  Obst.  Trans.,  vol.  viii. 


CjEsarean  section.  523 

by  clean  soft  sponges  dipped  in  warm  water.  Tlie  abdominal  wound 
slioidd  be  closed  from  above  downward  by  harelip  pins,  wire  or  silk 
sutures,  which  should  be  inserted  at  a  distance  of  an  inch  from  each 
other  and  passed  entirely  through  the  abdominal  walls  and  the  perito- 
neum at  some  little  distance  from  the  edges  of  the  «ncision,  so  as  to 
bring  the  two  surfaces  of  the  peritoneum  into  contact.  By  this  means 
we  ensure  the  closure  of  the  peritoneal  cavity,  the  opposed  surfaces 
adhering  with  great  rapidity.  If,  as  should  be  the  case,  the  operation  is 
performed  with  full  antiseptic  precautions,  the  wound  should  no^v  be 
dressed  precisely  as  after  ovariotomy. 

Subsequent  Management. — Into  the  subsequent  treatment  it  is  unneces- 
sary to  enter  at  any  length,  since  it  must  be  regulated  by  general  princi- 
ples, each  symptom  being  met  as  it  arises.  It  has  been  customary  to 
administer  opiates  freely  after  the  operation,  but  they  seem  to  have  a 
tendency  to  produce  sickness  and  vomiting,  and  ought  not  to  be  exhib- 
ited unless  pain  or  peritonitis  indicates  that  they  are  required.  In  fact, 
the  treatment  should  in  no  way  differ  from  that  usual  after  ovariotomy, 
and  the  principles  that  should  guide  us  will  be  best  shown  by  the  follow- 
ing quotation  from  Mr.  Spencer  Wells's  description  of  that  operation  : 
"The  principles  of  after-treatment  are — to  obtain  extreme  quiet,  com- 
fortable warmth,  and  perfectly  clean  linen  to  the  patient ;  to  relieve  pain 
by  warm  applications  to  the  abdomen  and  by  opiate  enemas;  to  give 
stimulants  when  they  are  called  for  by  failing  pulse  or  other  signs  of 
exhaustion;  to  relieve  sickness  by  ice  or  iced  drinks;  and  to  allow  plain, 
simple,  but  nourishing  food.  The  catheter  must  be  used  every  six  or 
eight  hours  until  the  patient  can  move  without  pain.  The  sutures  are 
removed  on  the  third  day,  unless  tympanitic  distension  of  the  stomach 
or  intestines  endangers  reopening  of  the  wound.  In  such  circumstances 
they  may  be  left  for  some  days  longer.  The  superficial  sutures  may 
remain  until  union  seems  quite  firm." 

\_Improved  Methods  of  Perforining  Gastro-liysterotomy. — These,  with 
one  exception — that  of  Dr.  Garrigues  of  New  York — come  from  Ger- 
many, where  there  is  a  disposition  to  revive  the  old  Csesarean  operation 
in  consequence  of  that  of  Porro  having  saved  in  that  country  but  a  frac- 
tion over  32  per  cent,  of  the  women.  The  new  antiseptic  processes  are 
devised  by  Cohnstein  and  Kehrer  of  Heidelberg,  Frank  of  Cologne, 
and  Sanger  of  Leipzig.  Cohnstein's^  process  has  not  yet  been  tested. 
He  proposes  to  turn  out  the  uterus  entire ;  open  it  vertically  through 
the  posterior  wall ;  deliver  the  foetus  and  secundines  ;  replace  the  organ, 
and  pass  a  drainage-tulje  througli  tlie  Douglas  cid-de-sae  and  vagina ; 
and  close  the  abdominal  wound.  He  directs  that  compression  of  tlie 
aorta  shall  be  made  during  the  opening  and  contraction  of  the  uterus 
to  check  the  loss  of  blood. 

Frank\s  Prooejis.'^ — Wash  the  abdomen  over  with  ether  and  Avith  a  5 
pfT  f;ent.  solution  of  carbolic  acid  ;  disinfect  the  vagina  by  irrigating 
witl)  the  latter  fiuid.  Turn  out  the  uterus,  and  o])en  it  vertically  in 
front,  comnuMicing  the  incision  low  down  in  the  vcsico-ut(!rine  excava- 
tion ;  extract  the  fijetus  and  secundines  ;  wash  the  front  of  the  uterus,  its 

[1  antralhlntt  fur  GyndkoJ.,  1881,  No.  12,  vol.  v.  p.  290.] 
P  Ibid.,  1881,  No.  25,  vol.  V.  p.  598.] 


524  OBSTETRIC  OPERATIONS. 

interior,  and  the  vagina  with  tlie  5  per  cent,  carbolic-acid  solution.  Pass 
a  large  drainage-tube  througli  the  abdominal  and  uterine  wounds  and  out 
through  the  vagina.  Suture  the  uterus  above  the  tube;  draw  the  round 
ligaments  together  above  the  uterine  wound,  and  secure  them  with  sutures 
of  Czerny  silk,  s#  as  to  close  over  and  separate  the  vesico-uterine  pouch 
from  the  abdominal  cavity.  Drainage  is  to  be  made  by  three  tubes — 
''  one  utero-vaginal,  one  pre-uterine,  and  a  third  applied  along  the  ute- 
rine wound  to  the  top  of  the  pavilion."  This  operation  has  been  per- 
formed in  the  interest  of  the  foetus  upon  a  badly-burned  woman,  who 
survived  for  ten  hours ;  the  child  was  saved. 

Kehrer^s  Process? — In  this  form  of  operation"  the  uterus  is  to  be 
opened  transversely  and  low  down  in  front.  After  delivery  close  tlie 
muscular  layer  of  the  uterus  by  from  six  to  ten  deep-seated  sutures  of 
carbolized  silk,  and  the  peritoneal  portion  by  from  twelve  to  twenty-five. 
Use  Listerism  in  the  operation  and  dressings,  abdominal  drainage,  and 
vaginal  irrigation.  This  operation  has  been  performed  with  entire  success 
upon  a  malacosteon  subject  of  26  years  of  age.  In  a  second  case  it  resulted 
fatally,  the  wound  in  the  uterus  not  having  been  thoroughly  closed. 

Sanger's  Process.^ — After  the  abdominal  incision  is  made  insert  two 
strong  ligatures  through  the  margins  of  the  wound  near  its  upper  angle, 
to  be  drawn  upon  after  turning  out  the  uterus.  Rupture  the  membranes 
through  the  vagina.  If  practicable,  turn  out  the  uterus  and  hold  it 
vertically.  A  sheet  of  caoutchouc,  moistened  with  a  5  per  cent,  carbolic- 
acid  solution,  is  to  be  made  to  enclose  the  cervix  and  cover  the  abdomen 
as  a  protector,  and  the  ligatures  are  to  be  drawn  while  the  uterus  is  being 
incised  vertically  in  front  and  evacuated.  If  the  organ  is  incised  in  situ, 
manual  compression  is  to  be  made  upon  its  lower  segment  as  a  haemo- 
static. If  turned  out  first,  then  the  same,  or  the  application  of  clamps 
to  the  broad  ligaments  or  of  an  elastic  tube  to  the  cervix.  After  evacu- 
ating the  uterus  use  haemostatic  pincettes  if  the  edges  of  the  uterine 
wound  bleed.  When  the  uterus  is  well  contracted  pass  a  utero-vaginal 
drainage-tube,  and  introduce  a  carbolized  sponge  into  the  uterine  cavity  ; 
then  dissect  the  peritoneum  free  from  the  muscular  edges  of  the  uterine 
wound,  and  pare  from  the  latter  on  each  side  a  long  slice  of  tissue  of  a 
wedge  shape,  the  thick  edge  being  next  to  the  peritoneal  side.  Turn  in 
the  free  edges  of  the  peritoneum  over  the  muscular  layer,  and  unite  by 
deep-seated  sutures  of  silver  wire  or  silk ;  then  bring  the  serous  sur- 
faces of  peritoneum  in  contact,  and  secure  them  by  numerous  superficial 
sutures. 

Three  operations  under  this  method,  performed  by  Dr.  Leopold  of 
Dresden,  saved  all  the  women  and  children,  who  continued  in  good 
health  at  the  last  report.  A  fourth  case,  under  Dr.  Beumer,  was  lost,  as 
the  subject  was  in  bad  health  from  cystitis  and  pyelo-nephritis,  and  sur- 
vived but  forty  hours ;  the  child  was  saved.  At  the  late  International 
Medical  Congress  of  Copenhagen,  Dr.  Leopold  expressed  the  opinion 
that  in  future  operations  he  would  be  able  to  protect  the  abdominal 
cavity  against  uterine  leakage  without  the  resection  by  folding  in  the 
cut  edges  of  the  peritoneum  in  suturing  the  uterine  wound.     This  was 

l^Archivfiir  GyndkoL,  1882.  No.  2,  vol.  xix.  p.  180.] 
P  Ibid.,  1882,  No.  3,  vol.  xix.  p.  397.] 


CESAREAN  SEGTION.  525 

proved  on  autopsy  to  have  been  accomplished  in  the  operation  of  Dr. 
Garrigues  of  New  York,  performed  on  October  6,  1882.^  The  uterine 
wound  was  entirely  united,  but  the  woman,  who  lived  50  hours,  never 
recovered  from  the  eifect  of  a  severe  ante-partum  hemorrhage  :  her  pulse 
at  the  time  of  the  operation  was  124.  Two  of  the  Leopold  operations 
were  performed  since  that  of  Dr.  Garrigues. — Ed.] 

[T/ie  Results  of  the  Ccesarean  Operation  in  Great  Britain  and  the 
United  States  Compared. — The  fear  of,  and  opposition  to,  the  operation 
in  Great  Britain  are  very  natural  results  of  the  general  fatality  which 
has  attended  it,  even  when  performed  early  and  by  the  most  skilful 
hands.  It  was  for  a  long  time  claimed  that  the  delay  in  operating  con- 
stituted the  chief  cause  of  the  mortality  of  the  Csesarean  section  in  the 
British  Isles  as  compared  to  that  on  the  Continent ;  but  this  can  be 
shown  to  be  an  error,  as  there  have  been  operations  enough  performed 
in  good  season  to  prove  that  gastro-hysterotomy ,  per  se,  is  very  fatal  to 
British  women.  I  have  elsewhere  given  a  record  of  28  early  operations 
performed  in  the  United  States,  showing  a  recovery  of  75  per  cent,  of 
the  women,  23  of  the  children  being  delivered  alive.  By  a  careful 
selection  from  the  138  British  cases  I  have  formed  a  table  of  33  opera- 
tions, 23  of  which  were  performed  upon  women  not  over  twelve  hours 
in  labor,  and  10  from  twelve  to  eighteen  hours ;  and  the  results  are  as 
follows : 

Labor  induced,  1  case ;  fatnl  to  the  mother,  child  alive. 

Labor  not  commenced,  3  cases ;  2  mothers  recovered,  children  all  living,  2  premature. 

Labor  lasting  from  two  to  ten  hours,  inclusive,  11  cases;  all  fatal,  8  children  alive. 

Recorded  as  "early,"  1  case;  mother  saved,  child  dead. 

Labor  recorded  as  having  been  in  progress  a  few  hours  ;  mother  and  child  saved. 

Labor  from  eleven  to  sixteen  hours,  inclusive,  8  cases ;  1  woman  saved,  7  children 
alive. 

Labor  from  seventeen  to  eighteen  hours,  inclusive,  8  cases ;  3  women  saved,  5  chil- 
dren alive. 

Of  the  33  cases,  25  averaged  in  labor  eleven  and  a  half  hours,  and 
but  4  of  them  were  saved.  There  were  17  cases  not  exceeding  ten 
hours  in  labor,  of  which  4  were  saved ;  and  16  cases  from  eleven  to 
eighteen  hours  in  labor,  and  there  were  likewise  4  women  saved.  The 
mortality  of  the  cases,  even  when  seasonably  operated  upon,  may  there- 
fore be  set  down  at  75  per  cent.,  against  25  per  cent,  of  like  cases  in  the 
United  States.  The  general  average  of  recoveries  in  our  country  is  now 
al^out  40  per  cent. ;  we  therefore  save  more  than  2  cases  for  1  that  recov- 
ers in  Great  Britain ;  and  of  seasonable  operations  the  recoveries  are  as 
3  to  1.  This  difference  in  our  favor  can  only  be  accounted  for  by  the 
difference  of  physical  condition  in  the  subjects.  As  in  the  United  States 
and  France  the  women  of  the  farm  and  village  are  much  more  likely  to 
recover  than  those  of  the  cities,  so  likewise  the  better  fed  and  less  intem- 
perate poor  of  our  country  have  a  decided  advantage  over  their  less-fav- 
ored sisters  in  England,  where  81  per  cent,  have  perished  against  60  per 
cent,  in  the  United  States. — Ed.]  • 

Porro's  Operation. — Within  the;  last  few  years  an  important  modifi- 
cation of  the  Ca3sarean  section  has  l^een  adopted,  whicli  is  generally 
known  as  Porro's  operation,  from  Professor  Porro  of  Pavia,  who  was 
[^  American  Journ.  of  Obaletrics,  April,  1883,  p.  344.] 


526  OBSTETRIC  OPERATIONS. 

the  first  European  surgeon  who  practised  it.  In  tliis  operation,  after 
the  uterus  is  emptied,  the  entire  organ  is  drawn  out  of  the  abdominal 
wound  and  excised,  its  neck  being  first  constricted  so  as  to  suppress 
hemorrhage,  the  stump  being  fixed  externally  in  the  manner  of  the 
pedicle  in  ovariotomy.  The  idea  is  by  no  means  new.  It  appears  to 
have  been  first  suggested  by  an  Italian — Dr.  Cavallini — in  1768.  In 
1823  the  late  Dr.  Blundell  made  the  same  proposal,  and  fortified  it 
by  numerous  experiments  on  pregnant  rabbits,  in  the  course  of  Avhich 
he  found  that  he  lost  all  by  the  Cesarean  section,  but  saved  3  out  of  4 
in  which  he  ligatured  and  amputated  the  uterus.  The  suggestion  was 
not,  however,  carried  into  actual  practice  until  Dr.  Storer  of  Boston  in 
"^869  removed  the  uterus  in  a  case  of  fibroid  tumor  obstructing  the 
pelvis  and  impeding  delivery. 

Since  Porro's  first  case  the  operation  has  been  frequently  performed 
on  the  Continent,  with  results  which  are,  on  the  whole,  encouraging. 
The  cases  have  been  carefully  tabulated  by  Dr.  Harris  of  Philadelphia, 
and  more  recently,  and  very  completely,  by  Dr.  Clement  Godson,'  who 
has  collected  138  cases,  out  of  Avhich  61,  or  55.8  per  cent.,  were  success- 
ful as  regards  the  mother.  This  result  is  certainly  superior  to  those  fol- 
lowing the  Cesarean  section  as  ordinarily  performed.  The  obvious 
advantage  of  this  plan  is  that  instead  of  leaving  the  incised  uterus  with 
its  probably  gaping  wound  and  all  the  attendant  risk  of  septic  mischief 
in  the  abdominal  cavity,  it  is  fixed  externally,  and  in  a  position  where  it 
can  be  readily  dressed. 

The  objection  is  that  it  entirely  unsexes  the  patient,  but  in  the  class 
of  women  requiring  the  Csesarean  section  from  pelvic  deformity  it  is 
questionable  whether  this  can  be  fairly  considered  as  a  drawback.  It  is 
perhaps  not  justifiable  to  attempt  as  yet  any  positive  decision  as  to  the 
indications  for  this  plan,  but  it  seems  beyond  doubt  that  the  risks  are 
considerably  less  than  those  of  the  Csesarean  section. 

The  Operation. — The  operation  in  the  successful  cases  has  been  per- 
formed under  the  carbolic  spray,  and  the  neck  of  the  uterus,  after  the 
organ  is  emptied,  carefully  secured  by  ligatures  before  its  body  is  ampu- 
tated. Some  operators  have  encircled  the  neck  of  the  uterus  ^vith  a 
chain  or  wire  ^craseur  before  removing  it,  and  by  this  means  completely 
controlled  hemorrhage.  Richardson^  transfixed  the  neck  of  the  uterus 
with  U\o  large  pins  crossing  each  other  before  removing  the  wire  of  the 
^craseur,  and  encircled  them  with  stout  carbolized  cord.  IMiiller  of 
Berne  has  recommended  that  the  entire  uterus  should  be  turned  out  of 
the  abdominal  cavity  through  a  long  incision  before  it  is  emptied,  so  as 
to  avoid  the  risk  of  its  fluid  contents  entering  the  abdomen  ;  but  this 
manoeuvre  has  not  always  proved  feasible.  The  pedicle  has  generally 
been  fixed  in  the  lower  angle  of  the  abdominal  wound  and  dressed  anti- 
septically.  In  most  cases  one  or  more  drainage-tubes  have  been  used, 
either  through  Douglas's  space  or  in  the  abdominal  wound. 

\_Latest  Porro-'Ccesarean  Statistics.^ — Dr.  Clement  Godson  of  London 
has  recently  added  15  cases  to  his  former  tabular  record  of  137,  and 

'  Porro's  Operation,  Brit.  Med.  Jnurn.,  Jan.  26,  1884. 
-  Americnii  Jonrn.  of  Med.  Science,  Jiilv,  1881. 
[^  Brit.  Med.  Journ.,  Jan.  17,  1885,  p.  120.] 


CESAREAN  SECTION.  527 

thereby  increased  it  to  152,  and  Dr.  Ettore  Truzzi^  of  Milan  has  ob- 
tained by  correspondence  .12  more,  making  the  whole  164  cases,  saving 
69  women  and  129  children.  The  average  number  of  operations  per 
annum  for  the  past  five  years  has  been  25 ;  those  of  1884,  as  far  as  ascer- 
tained, amount  to  23,  with  only  9  women  saved,  although  19  children 
were  living.  Of  tlie  164  cases,  109  were  operated  upon  by  the  method 
of  Porro,  many  of  them  very  unfavorable,  and  46  were  saved ;  41  by 
the  modification  of  Miiller,  with  21  recoveries;  and  14  by  that  of  Veit, 
of  dropping  in  the  stump,  with  10  deaths.  In  6  cases  the  Midler  method 
failed  of  completion  after  making  the  long  incision,  and  the  operations 
were  completed  by  the  plan  of  Porro,  by  which  4  were  saved.  Of  166 
children  extracted  (2  women  bore  twins),  129  were  "living,"  hut  not  in 
a  moribund  condition,  and  37  were  dead  or  moribund.  The  Italian  ope- 
rators saved  53  out  of  69  children;  the  Germans  saved  18,  and  lost  10; 
the  Austrians  32,  and  lost  3 ;  the  French  10,  and  lost  5 ;  English  and 
Scotch  6,  and  lost  3 ;  the  United  States  2,  and  lost  1 ;  Belgians  4,  lost 
0;  and  Swiss  2,  lost  0. 

The  operations  in  private  houses  number  23,  of  which  10  recovered 
and  13  clied.  The  best  hospital  work  was  done  in  Milan,  where  five 
operators  in  Santa  Caterina  saved  10  women  out  of  13,  and  all  of  the 
children.  In  the  Krankenhaus  of  Vienna,  13  women  and  23  children 
were  saved  by  26  operations.  By  excluding  3  moribund  cases  and  the 
14  Veit  experiments  from  the  164  operations,  leaving  the  Porro  and 
Porro-Miiller  cases  only,  we  have  147,  saving  65  women,  or  44  per 
cent. ;  which  I  now  regard  as  the  true  status  of  the  "  Porro  operation." 
These  may  be  subdivided  into  ^0  favorable  cases,  of  which  53  recovered, 
or  58y^jj  per  cent. ;  and  57  unfavorable,  of  which  only  13  were  saved,  or 
less  than  23  per  cent. 

The  greatest  degree  of  success  has  been  attained  in  Austria,  where 
nine  operators  saved  20  out  of  34  women,  or  nearly  59  per  cent.  Under 
forty-three  operators  in  Italy,  28  out  of  65  women  were  saved,  or  43^ 
per  cent.  Germany,  under  sixteen  operators,  lost  19  out  of  28,  and  4 
of  the  9  saved  were  by  Dr.  Fehling  of  Stuttgart,  who  lost  only  1  out  of 
his  5  cases.  France  saved  5  out  of  15,  and  Great  Britain  1  out  of  9. 
In  this  enumeration  no  case  is  counted  where  the  foetus  was  non-viable. 
Prof  Breisky  of  Prague  saved  all  of  his  5  cases,  and  Prof  Porro  him- 
self 4  out  of  5. — Ed.] 

Substitute  for  the  Ccesarean  Section. — Bearing  in  mind  the  great  mor- 
tality attending  the  Csesarean  section,  it  is  not  surprising  that  obstetri- 
cians should  have  anxiously  considered  the  possibility  of  devising  a  sub- 
stitute which  should  afford  the  mother  a  better  chance  of  recovery.  The 
first  proposal  of  the  kind  was  one  from  which  great  results  were  at  first 
anticipated.  In  1768,  Sigault,  then  a  student  of  medicine  in  Paris,  sug- 
gested symphyseotomy,  which  consists  in  the  division  of  the  symphysis 
pubis,  with  a  view  of  allowing  the  pubic  bones  to  separate  sufficiently 
to  admit  of  the  passage  of  the  child.  Although  at  first  strongly  oj^jiosed, 
it  was  sul)scquently  ard(!ntly  advocated  by  many  obstetricians,  and  was 
often  ])crf()rnied  on  the  Continent  and  in  a  few  cases  in  this  country. 

The  Operation  is  Admitted  fo  he    Useless. — It  is  generally  admitted 

['  Annali  Univermll  rli  MexUcimi,  Milano,  Oct.,  1884,  p.  387,  and  Nov.,  1884,  p.  401.] 


528  OBSTETRIC  OPERATIONS. 

that  it  is  quite  impossible  to  make  this  a  substitute  for  the  Ceesarean 
section,  since  the  utmost  gain  which  even  a  wide  separation  of  tlie  sym- 
physis pubis  would  give  would  be  altogether  insufficient  to  admit  of  the 
passage  of  even  a  mutilated  foetus.  Dr.  Churchill  concludes  that  even 
if  it  were  possible  to  separate  it  to  the  extent  of  four  inches,  we  should 
only  have  an  increase  of  from  four  lines  to  half  an  inch  in  the  antero- 
posterior diameter,  in  which  the  obstruction  is  generally  most  marked. 
In  the  lesser  degrees  of  deformity  this  might  possibly  be  sufficient  to 
allow  the  foetus  to  pass,  but  the  risk  of  the  operation  itself  and  the 
subsequent  ill-effects  altogether  contraindicate  it  in  cases  of  this 
description. 

\_Possibiliiies  of  Gastro-hysterotomy. — Old  as  it  is,  the  Cesarean  opei'a- 
tion  is  still  upon  trial,  and  has  by  no  means  attained  the  minimum  of 
mortality  of  wdiich  it  is  capable  under  modern  improvements  as  one  of 
the  forms  of  abdominal  surgery.  The  Porro  method  has  demonstrated 
the  importance  of  securing  the  abdominal  cavity  against  the  entrance  of 
septic  matters  escaping  from  the  uterine  wound ;  and  its  modification  by 
Veit,  of  dropping  in  the  pedicle,  with  its  far  greater  fatality,  has  only 
tended  to  confirm  our  opinion  as  to  the  importance  of  preventing  all 
uterine  leakage.  But  is  there  no  way  of  rendering  the  uterine  wound 
as  water-tight  as  that  made  in  the  stomach  in  gastrotomy  when  secured 
by  the  suture  of  Gely  ?  We  believe  there  is.  When  the  peritoneal  coat 
of  the  uterus  is  so  stitched,  in  securing  the  uterine  wound,  as  to  make  it 
form  a  welt,  with  its  serous  surfaces  brought  in  contact,  as  in  the  Gely 
suture,  the  local  adhesive  peritonitis  which  follows  will  soon  efFectually 
secure  the  wound  against  the  possibility  of  fluid  passing  through  it. 
This  was  demonstrated  very  satisfactorily  in  the  Garrigues  case,  already 
quoted,  although  the  previous  condition  of  the  woman  gave  it  a  fatal 
termination ;  and  also  in  that  of  Drs.  Drysdale  in  Philadelphia  and 
Jewett  in  Brooklyn.  The  results  of  the  three  Leopold  operations  show 
more  decidedly  the  value  of  the  improvement,  having  all  recovered. 
As  far  as  ascertained  by  autopsy,  the  serous  surfaces  will  unite  within 
thirty  hours,  provided  the  uterine  muscular  tissue  is  sufficiently  firm  in 
texture  to  enable  the  deep-seated  sutures  to  hold  and  prevent  gaping. 
To  secure  this  condition  of  soundness  it  is  important  to  operate  early,  as 
it  is  also  to  save  the  strength  of  the  patient,  and  thus  secure  her  against 
shock  and  septic  peritonitis.  The  past  record  of  the  operation  in  the 
United  States  clearly  demonstrates  the  value  of  an  early  use  of  the 
knife,  and  the  future  ought  to  show  better  results  when  all  the  addi- 
tional precautions  recently  introduced  arc  made  use  of  In  a  large  pro- 
portion of  American  cases  we  would  not  be  justified  in  removing  the 
uterus,  as  under  the  Porro  method,  and  it  is  therefore  important  to 
diminish  the  risks  of  the  old  operation.  It  is  also  to  be  considered,  in 
view  of  past  success,  whether  an  improved  Csesarean  section  M'ill  not 
promise  better  results  than  the  dangerous  expedient  of  craniotomy  and 
evisceration  in  cases  where  the  foetus  is  impacted  in  a  transverse  posi- 
tion. These  considerations  are  purely  national,  as  the  records  of  Great 
Britain  give  very  little  encouragement  for  performing  gastro-hysterot- 
omv.  The  fact  that  25  children  were  delivered  alive  from  33  women 
operated  upon  within  eighteen  hours  after  the  commencement  of  labor 


LAPARO-ELYTROTOMY.  629 

shows  that  the  cases  were  not  lost  by  delay ;  yet  25  of  these  women  were 
lost — a  number  which  we  should  expect  to  save  in  this  country. — Ed.] 

\_The  revival  of  symphyseotomy  in  Italy,  and  its  greatly  improved 
results,  show  that  the  large  mortality  of  the  early  cases,  and  especially 
of  the  children,  was  due  to  the  foetus  having  been  either  turned  or  forci- 
bly delivered  before  its  head  had  time  to  become  moulded  to  the  form 
of  the  superior  strait,  the  value  of  which  process  is  set  forth  by  the 
author  on  page  397,  chap.  xii.  I  do  not  regard  so  much  the  gain  in 
the  conjugate  diameter  as  that  in  the  transverse  in  symphyseotomy ; 
certain  it  is  that  the  new  operation,  wherein  the  foetus  is  delivered  by 
the  forces  of  the  mother  in  the  large  majority  of  cases,  is  far  less  fatal  to 
her  and  the  foetus  than  the  original  one,  where  the  child  was  turned  and 
forced  into  the  world  by  traction,  to  its  fatal  injury,  and  the  injury  of 
the  woman  by  the  strain  upon  her  sacro-iliac  symphyses.  Under  Pro- 
fessors O.  Morisani  and  Novi  of  Naples  43  women  and  42  children  were 
saved  by  53  symphyseotomies  from  1866  to  1881.  "Symphyseotomy 
can  never  be  made  to  take  the  place  of  the  Csesarean  section  in  cases  of 
extreme  deformity,  as  its  advocates  are  not  inclined  to  recommend  it  in 
cases  having  a  conjugate  of  less  measure  than  67  millimeters,  or  2-| 
inches." 

For  a  full  exjDosition  of  the  subject  see  Harris  on  the  "  Revival  of 
Symphyseotomy  in  Italy"  in  Am.  Journ,  of  Med.  Sci.  for  Jan.,  1883  ; 
also  "Una  Probabile  Risurrezione  nel  Gampo  DelF  ostetricia  opera- 
tiva,"  in  the  Annali  cV  Ostetricia,  anno  v.,  1883,  by  Prof.  Mangiagalli 
of  the  University  of  Sassari,  Italy. — Ed.] 


CHAPTER  VII. 

LAPARO-ELYTKOTOMY. 

Ix  the  former  editions  of  this  work  laparo-elytrotomy  was  briefly  con- 
sidered as  one  of  the  suggested  substitutes  for  the  Csesarean  section  which 
merited  careful  study  and  appeared  to  be  of  a  promising  character,  but  of 
which  too  little  was  known  to  justify  any  positive  conclusions  with  regard 
to  it.  The  subject  naturally  attracted  considerable  attention,  and  several 
interesting  papers  have  appeared  in  which  its  indications,  diflficulties,  and 
advantages  have  been  carefidly  considered.  Since  Thomas's  first  case 
was  published  several  operations  have  been  performed,  with  results  so 
encouraging  that  I  cannot  but  believe  that  the  operation  has  a  great 
future  Ijcfore  it,  and  that  it  will  be  the  duty  of  the  a(!Coucheur  to  resort, 
to  it  instearl  of  the  more  hazardous  Ca'sarean  s(!ction,  unless  some  special 
contraindication  exists.  Under  tlicsc  cin^umstances  it  seems  proper  no 
long(!r  to  consider  it  as  an  addendum  to  tlie  description  of  the  Caisarean 
section,  l>ut  to  study  it  more  in  detail  in  a  separate  chapter. 

History. — The  history  of  the  operation  is  curious   and  interesting. 

34 


530  OBSTETRIC  OPERATIONS. 

The  earliest  suggestion  of  a  procedure  of  this  character  seems  to  have 
been  made  by  Joerg  in  the  year  1806,  who  proposed  a  modified  Csesa- 
rean  section,  without  incision  of  the  uterus,  by  the  division  of  the  linea 
alba  and  of  the  upper  part  of  the  vagina,  the  foetus  being  extracted 
through  the  cervix.  This  suggestion  was  never  carried  into  practice, 
and  it  is  obvious  that  it  misses  the  one  chief  advantage  of  laparo-elytrot- 
omy,  the  leaving  of  the  peritoneum  intact.  In  1820,  Ritgen  proposed, 
and  actually  attempted,  an  operation  much  resembling  Thomas's,  in 
which  section  of  the  peritoneum  was  avoided.  He  failed,  however,  to 
complete  it,  and  was  eventually  compelled  to  deliver  his  patient  by  the 
Csesarean  section.  In  1823,  Baudelocque  the  younger  independently 
conceived  the  same  idea,  and  actually  carried  it  into  practice,  although 
without  success.  Lastly,  in  1837,  Sir  Charles  Bell  suggested  a  similar 
operation,  clearly  perceiving  its  advantages.  Hence  it  appears  that  pre- 
vious to  Thomas's  recent  work  in  the  matter  the  operation  was  inde- 
pendently invented  no  less  than  three  times.  It  fell,  however,  entirely 
into  oblivion,  and  was  only  occasionally  mentioned  in  systematic  works 
as  a  matter  of  curious  obstetric  history,  no  one  apparently  appreciating 
the  promising  character  of  the  procedure. 

In  the  year  1870,  Dr.  T.  Gaillard  Thomas  of  New  York  read  a  paper 
before  the  Medical  Association  of  the  town  of  Yonkers  on  the  Hudson 
River,  entitled  "  Gastro-elytrotomy,  a  Substitute  for  the  Csesarean  Sec- 
tion," in  which  he  described  the  operation  as  he  had  performed  it  three 
times  on  the  dead  subject  and  once  on  a  married  woman  in  1870,  wjth  a 
successful  issue  as  regards  the  child.  It  seems  beyond  doubt  that  Thomas 
invented  the  operation  for  himself,  being  ignorant  of  Ritgen's  and  Bau- 
delocque's  previous  attempts,  and  it  is  certain,  to  quote  Garrigues,^  that 
to  him  "  belongs  the  glory  of  having  been  the  first  who  performed  gas- 
tro-elytrotomy so  as  to  extract  a  living  child  from  a  living  mother  in  his 
first  operation,  and  of  having  brought  both  mother  and  child  to  complete 
recovery  in  his  second  operation." 

Since  Thomas's  first  case  the  operation  has  been  performed  three 
times  by  Dr.  Skene  of  Brooklyn,  and  has  found  its  way  across  the 
Atlantic,  having  been  twice  performed  in  England,  by  Hime  in  Shef- 
field and  by  Edis  in  London.  P] 

Nature  of  the  Operation. — The  object  of  laparo-elytrotomy  is  to  reach 
the  cervix  by  incision  through  the  lower  part  of  the  abdominal  wall  and 
upper  part  of  the  vagina,  and  through  it  to  extract  the  foetus  as  may 
most  easily  be  done. 

Advanta(/es  over  the  Coesarean  Section. — If  this  procedure  is  found 
practicable,  the  enormous  advantages  it  offers  over  the  Csesarean  section 
are  at  once  apparent,  since  in  dividing  the  abdomen  the  abdominal  Avail 

1  New  York  Med.  Journ.,  Nov.,  1878. 

[■'Thomas  operated  twice;  Skene  four  times;  Charles  Jewett  of  Brooklyn  twice; 
Hime,  Edis,  Dandridge  and  Taylor  of  Cincinnati,  and  Walter  E.  Gillette  of  Kew 
York,  each  once  ;  in  all,  12.  Women  saved,  6;  children  living,  but  not  moribund,  7; 
bladder  lacerated  in  6  cases.  In  properly  calculating  the  risks  of  the  operation  it  is 
fair  to  exclude  the  moribund  case  of  Thomas,  the  intemperate  and  bedridden  one  of 
Hime,  and  the  diseased  .subject  of  Edis,  Avho  survived,  respectively,  one  hour,  two 
hours,  and  forty  hours.  The  balance,  9  cases,  were  favorable  in  4  instances  and  unfav- 
orable in  5  :  6  of  the  9  women  recovered,  and  5  children  were  saved.] 


LAPABO-ELYTBOTOMY.  531 

only  is  incised  and  the  peritoneum  is  left  intact.  The  vagina  is  divided, 
but  incision  of  the  uterine  parietes,  which  forms  one  of  the  chief  risks 
of  the  Csesarean  section,  is  entirely  avoided.  Now,  there  is  nothing  in 
either  of  these  procedures  alarming  in  itself,  and  if  further  experience 
proves  that  the  practical  difficulties  of  the  operation  do  not  stand  in  the 
way  of  its  adoption,  Dr.  Thomas  will  have  introduced,  by  his  able  advo- 
cacy of  the  operation,  probably  the  greatest  improvement  in  modern 
obstetrics. 

Cases  Suitable  for  the  Operation. — It  may  be  broadly  stated  that 
laparo-elytrotomy  is  applicable  in  all  cases  calling  for  the  Cesarean  sec- 
tion when  the  mother  is  alive.  In  post-mortem  extractions  of  the  foetus 
the  Csesarean  section,  being  the  most  rapid  procedure,  would  certainly  be 
preferable.  Exceptions  must  be  made  for  certain  cases  of  morbid  con- 
ditions of  the  soft  parts  which  render  delivery  per  vias  naturales  impos- 
sible, and  in  which  laparo-elytrotomy  could  not  be  performed,  as  in  cases 
of  tumor  obstructing  the  pelvic  cavity,  also  in  carcinoma  or  fibroid  of 
the  uterus.  When  the  head  is  firmly  impacted  in  the  pelvic  brim  and 
cannot  be  dislodged,  the  operation  would  be  impossible,  as  the  vagina 
could  not  be  incised.  Unlike  the  Csesarean  section,  the  operation  cannot 
be  performed  twice  on  the  same  patient,  at  least  on  the  same  side,  since 
adhesions  left  by  the  former  incisions  would  prevent  the  separation  of 
the  peritoneum  and  division  of  the  vagina.  It  remains  to  be  seen 
whether  in  certain  cases  of  extreme  deformity,  with  pendulous  abdomen 
and  distorted  thighs,  the  site  of  incision  might  not  be  so  difficult  to  reach 
as  to  render  the  necessary  manoeuvres  impossible. 

It  will  facilitate  the  proper  comprehension  of  the  operation,  and  ren- 
der an  avoidance  of  its  possible  dangers  more  easy,  if  the  anatomical 
relations  of  the  parts  concerned  are  briefly  described. 

Abdominal  Incision. — The  abdominal  incision  extends  from  a  point ' 
an  inch  above  the  anterior-superior  iliac  spine,  and  is  carried,  with  a 
slight  downward  curve,  parallel  to  Poupart's  ligament  until  it  reaches  a 
point  one  inch  and  three-quarters  above,  and  to  the  outside  of,  the  spine 
of  the  pubes.  Beyond  the  latter  point  it  must  not  extend,  so  as  to  avoid 
the  risk  of  wounding  the  round  ligament  and  the  epigastric  artery.  In 
this  incision  the  skin,  the  aponeurosis  of  the  external  oblique,  and  the 
fibres  of  the  internal  oblique  and  transversalis  muscles  are  divided.  The 
rectus  is  not  implicated.  After  the  muscles  are  divided  the  transversalis 
fascia  is  reached.  It  is  fortunately  rather  dense  in  this  situation,  and 
is  separated  from  the  peritoneum  by  a  layer  of  connective  tissue  contain- 
ing fat. 

Arteries. — The  superficial  epigastric  artery  is  necessarily  divided,  but 
is  too  small  to  give  any  trouble.  The  internal  epigastric  is  fortunately 
not  divided,  but  is  so  near  the  inner  end  of  the  incision  that  it  may  acci- 
dentally be  so.  In  one  of  Dr.  Skene's  operations  it  was  laid  bare. 
Starting  from  the  external  iliac,  about  a  quarter  of  an  inch  above  Pou- 
])art's  ligament,  it  runs  downward,  forward,  and  inward  to  the  ligament ; 
tlience  it  turns  upward  and  inward  in  front  of  the  round  ligament  and 
to  the  inner  side  of  the  internal  abdominal  ring,  behind  the  posterior 
layer  of  the  sheath  of  the  rectus  muscle,  whicli  it  finally  enters.  The 
circumflex  iliac  artery  also  rises  from  the  external  iliac  a  little  below  the 


532  OBSTETRIC  OPERATIONS. 

epigastric.  It  runs  between  the  peritoneum  and  Poupart's  ligament 
until  it  reaches  the  crest  of  the  ilium,  to  the  inner  side  of  which  it  runs. 
It  thus  lies  altogether  below  the  line  of  the  incision,  and  is  not  likely  to 
be  injured. 

Peritoneum. — After  the  transversalis  fascia  is  divided  the  peritoneum 
is  reached,  and  is  readily  lifted  up  intact,  so  as  to  expose  the  upper  part 
of  the  vagina,  through  which  the  foetus  is  extracted.  It  is  fortunate,  as 
facilitating  this  mancjeuvre,  that  the  peritoneum  is  much  more  lax  than 
in  the  non-pregnant  state,  and  it  has  been  found  very  easy  to  lift  it  out 
of  the  way  in  all  the  operations  hitherto  performed. 

Vaginal  Incision. — The  division  of  the  vagina  is  the  part  of  the  ope- 
ration likely  to  give  rise  to  most  trouble  and  risk.  It  is  to  be  noted 
that  in  cases  of  pelvic  contraction  calling  for  this  operation  the  uterus, 
with  its  contents,  will  be  abnormally  high  and  altogether  above  the  pel- 
vic brim  ;  the  vagina  is  therefore  necessarily  elongated  and  brought  more 
readily  wiJ:hin  reach.  It  is  enlarged  in  its  upper  part  during  pregnancy, 
and  thrown  into  folds  ready  for  dilatation  during  the  passage  of  the 
child.  It  is  loosely  surrounded  by  the  other  tissues,  and  is  composed  of 
muscular  fibres,  easily  separable,  and  an  internal  mucous  layer.  Its 
vascular  arrangements  are  very  complex,  and  the  risk  of  hemorrhage 
is  one  of  the  prominent  difficulties  of  the  operation. 

In  Baudelocque's  attempt,  in  which  the  vagina  was  cut  instead  of 
torn,  the  loss  of  blood  was  so  great  as  to  lead  to  a  discontinuance  of  the 
operation.  The  arteries  are  numerous,  consisting  of  branches  from  the 
hypogastric,  inferior  vesical,  internal  pudic,  and  hemorrhoidal.  The 
veins  form  a  network  surrounding  the  whole  canal,  but  are  largest  at 
its  extremities,  so  that  it  is  desirable  to  open  the  vagina  as  low  down  as 
possible. 

Relations  of  the  Vagina. — Behind  the  vagina  lies  the  pouch  of  perito- 
neum known  as  Douglas's  space,  and  below  that  the  rectum.  In  front 
of  it  lies  the  bladder,  and  the  risk  of  injuring  that  viscus  or  the  ureter 
entering  it  constitutes  another  of  the  dangers  of  the  operation.  The 
relations  of  these  parts  have  been  specially  studied  by  Garrigues  ^  with 
the  view  of  facilitating  the  safe  performance  of  the  operation,  and  I 
quote  his  description : 

"  The  anterior-superior  surface  of  the  vagina  is,  in  its  upper  part, 
bound  by  loose  connective  tissue  to  the  bladder  on  a  surface  that  has  the 
shape  of  a  heart.  In  the  lower  or  anterior  part  the  boundary-line  of 
this  surface  runs  parallel  to  and  a  little  outside  of  the  trigonum  vesicale. 
In  the  upper  part  it  follows  the  outline  of  the  vagina,  from  which  it 
passes  over  to  the  cervix.  The  distance  from  the  internal  opening  of  the 
urethra  to  the  neck  of  the  womb  is  one  inch  and  a  quarter  (3.2  centi- 
meters). The  bladder  extends  five-eighths  of  an  inch  (1.5  centimeters) 
upon  the  cervix.  It  is  very  liable  to  be  reached  by  the  vaginal  rent  if 
the  latter  is  made  too  high  up  or  too  horizontal.  The  lower  part  of  the 
antero-superior  wall  carries  in  the  middle  line  the  urethra.  In  the 
uppermost  part,  a  little  outside  of  and  behind  the  bladder,  lies  the  ureter. 
In  order  to  avoid  the  ureter  and  the  bladder,  the  incision  of  the  vagina 
should  be  made  nearly  an  inch  and  a  half  (3.8  centimeters)  below  the 

^  Loc.  cit.,  p.  479. 


LAP  ABO-EL  YTROTOMY.  533 

uterus,  and  in  a  direction  parallel  to  the  ureter  and  the  boundary-line 
between  the  bladder  and  the  vagina." 

The  Operation. — The  operation  has  hitherto  been  performed  on  the 
right  side  only.  In  consequence  of  the  position  of  the  rectum  on  the 
left,  it  seems  doubtful  if  the  difficulties  of  performing  it  on  that  side 
would  not  render  the  operation  impossible.  This  point  can  only  be 
cleared  up  by  experience,  and  in  the  mean  time  the  right  side  should  cer- 
tainly be  selected.  For  the  proper  performance  of  the  operation  four 
assistants  are  necessary,  besides  one  who  administers  the  anaesthetic. 
The  patient  is  placed  on  her  back  on  the  operating-table,  with  pelvis 
raised  and  in  the  same  position  as  for  ovariotomy.  In  consequence  of 
access  of  air  jjer  vaginam  strict  antiseptic  precautions  cannot  be  adopted. 
Before  commencing  the  operation  the  cervix  is  dilated  as  much  as  pos- 
sible by  Barnes's  bags,  assisted,  if  necessary,  by  digital  dilatation. 

The  operator  stands  on  the  right  side  of  the  patient,  while  an  assist- 
ant, standing  on  her  left,  lays  his  hand  on  the  uterus  and  draws  it  up- 
ward and  to  the  left,  so  as  to  put  the  skin  on  the  stretch.  The  incision 
is  commenced  at  a  point  one  inch  above  the  anterior-superior  spine  of 
the  ilium,  and  is  carried  inward,  in  a  slightly  curved  direction,  until  it 
reaches  a  point  one  and  three-quarter  inches  above  and  outside  the  spine 
of  the  pubes.  The  skin  and  muscular  and  aponeurotic  tissues  are  care- 
fully divided,  layer  by  layer,  any  arterial  branches  being  secured  as  they 
are  severed,  until  the  transversalis  fascia  is  reached.  This  is  raised  by  a 
fine  tenaculum,  and  an  aperture  is  made  in  it,  through  which  a  director 
is  introduced,  and  on  this  the  fascia  is  divided  in  the  whole  length  of 
the  superficial  incision.  The  operator  now  separates  the  peritoneum  from 
the  transversalis  and  iliac  fascia  with  his  fingers,  and  an  assistant,  placed 
on  his  left,  elevates  it,  as  well  as  the  contained  intestines,  by  means  of  a 
fine  warmed  napkin,  and  keeps  it  well  out  of  the  way  during  the  rest 
of  the  operation.  A  third  assistant  now  introduces  a  silver  catheter  into 
the  bladder,  and  holds  it  in  the  position  of  the  boundary-line  between  it 
and  the  vagina  and  below  the  uterus. 

A  blunt  wooden  instrument  like  the  obturator  of  a  speculum  is  intro- 
duced into  the  vagina,  which  is  pushed  up  by  it  above  the  ilio-pectineal 
line.  On  this  an  incision  is  made  by  Paquelin's  thermo-cautery,  heated 
to  a  red  heat  only,  as  far  below  the  uterus  as  possible,  and  parallel  to  the 
ilio-pectineal  line  and  the  catheter  felt  in  the  bladder.  When  the  vagina 
has  been  burnt  through,  the  index  fingers  of  both  hands  are  pushed 
tlirough  the  incision,  and  the  vagina  torn  through  as  far  forward  as  is 
deemed  safe  by  the  guide  of  the  catheter  in  the  bladder  and  as  far  back- 
ward as  possible.  When  this  has  been  done  the  uterus  is  depressed  to 
the  left  and  the  cervix  lifted  into  the  incision  by  tlie  fingers,  and  the 
meml)ranes  are  rui)turcd.  Through  the  cervix  thus  elevated  the  child  is 
extracted,  according  to  the  presentation,  either  by  sim[)le  traction,  by  the 
forceps,  or  by  turning.  Before  concluding  the  operation  the  bladder 
shoidd  be  injected  with  milk,  to  make  sure  that  it  has  not  been  wounded. 
Should  it  be  so,  the  laceration  may  be  at  once  united  by  carbolized  gut. 
The  ])rincij)a]  risk  at  this  stage;  is  hemorrliage  from  the  vaginal  vessels, 
which,  however,  fortunately  did  not  giv(!  rise;  to  much  troul)le  in  any  of 
tlie  recent  operations.    If  it  occurs,  it  nuist  be  dealt  with  as  best  we  can, 


534  OBSTETRIC  OPERATIONS. 

either  by  ligature,  by  the  actual  cautery,  or  by  thoroughly  plugging  the 
vaginal  wound  with  cotton  wool  both  through  the  incision  and  per 
vaginam.  If  the  latter  be  not  necessary,  the  wound  should  be  cleaned 
by  injecting  a  warm  solution  of  weak  carbolized  water  (2  per  cent.),  its 
edges  united  by  interrupted  sutures,  and  dressed  as  is  deemed  best.  The 
subsequent  treatment  must  be  conducted  on  general  surgical  principles, 
and  will  much  resemble  that  necessary  after  other  severe  abdominal 
operations,  such  as  ovariotomy.  The  vagina  should  be  gently  syringed 
two  or  three  times  daily  with  a  weak  antiseptic  lotion.  The  diet  should 
be  light  and  nutritious,  chiefly  consisting  of  milk,  beef-tea,  and  the  like. 
Pain,  pyrexia,  etc.  must  be  treated  as  they  arise. 

[Laparo-elytrotomy  has  been  performed  but  four  times  since  January, 
1880.  The  skill  and  number  of  assistants  it  requires  must  necessarily 
limit  its  adoption.  It  may  be  performed  with  equal  facility  on  the  left 
side,  as  was  shown  in  1878  by  the  operation  of  Dr.  Hime  in  England, 
and  in  1883  by  that  under  Drs,  Danclridge  and  Taylor  of  Cincinnati,  in 
neither  of  which  cases  was  the  bladder  injured.  Dr.  Taylor  prefers  the 
left-side  operation  as  more  convenient  than  the  right.  In  57  of  the  1 34 
Cesarean  operations  of  the  United  States  laparo-elytrotomy  would  have 
been  impracticable. — Ed.] 


CHAPTER  VIII. 

THE  TEANSFUSION  OF  BLOOD. 

The  transfusion  of  blood  in  desperate  and  apparently  hopeless  cases 
of  hemorrhage  offers  a  possible  means  of  rescuing  the  patient  which 
merits  careful  consideration.  It  has  again  and  again  attracted  the  atten- 
tion of  the  profession,  but  has  never  become  popularized  in  obstetric 
practice.  The  reason  of  this  is  not  so  much  the  inherent  defects  of  the 
operation  itself — for  quite  a  sufficient  number  of  successful  cases  are 
recorded  to  make  it  certain  that  it  is  occasionally  a  most  valuable 
remedy — but  the  fact  that  the  operation  has  been  considered  a  delicate 
and  difficult  one,  and  that  it  has  been  deemed  necessary  to  employ  a 
complicated  and  expensive  apparatus  which  is  never  at  hand  when  a 
sudden  emergency  arises.  Whatever  may  be  the  difference  of  opinion 
about  the  value  of  transfusion,  I  think  it  must  be  admitted  that  it  is  of 
the  utmost  consequence  to  simplify  the  process  in  every  possible  way ; 
and  it  is  above  all  things  necessary  to  show  that  the  steps  of  the  opera- 
tion are  such  as  can  be  readily  performed  by  any  ordinarily  qualified 
practitioner,  and  that  the  apparatus  is  so  simple  and  portable  as  to  make 
it  easy  for  any  obstetrician  to  have  it  at  hand.  There  are  comparatively 
few  who  would  consider  it  worth  while  to  carry  about  with  them,  in 
ordinary  every-day  work,  cumbrous  and  expensive  instruments  which 
may  never  be  required  in  a  lifelong  practice  ;  and  hence  it  is  not  unlikely 
that  in  many  cases  in  which  transfusion  might  have  proved  useful  the 


THE  TRANSFUSION  OF  BLOOD.  535 

opportunity  of  using  it  has  been  allowed  to  slip.  Of  late  years  the 
operation  has  attracted  much  attention,  the  method  of  performing  it  has 
been  greatly  simplified,  and  I  think  it  will  be  easy  to  prove  that  all  the 
essential  aj)paratus  may  be  purchased  for  a  few  shillings,  and  in  so  port- 
able a  form  as  to  take  up  little  or  no  room,  so  that  it  may  be  always 
carried  in  the  obstetric  bag  ready  for  any  possible  emergency. 

History  of  the  Operation. — The  history  of  the  operation  is  of  con- 
siderable interest.  In  Villari's  Life  of  Savonarola  it  is  said  to  have 
been  employed  in  the  case  of  Pope  Innocent  VIII.  in  the  year  1492, 
but  I  am  not  aware  on  what  authority  the  statement  is  made.  The  first 
serious  proposals  for  its  performance  do  not  seem  to  have  been  made 
until  the  latter  half  of  the  seventeenth  century.  It  was  first  actually 
performed  in  France  by  Denis  of  Montpellier,  although  Lower  of  Oxford 
had  previously  made  experiments  on  animals  which  satisfied  him  that  it 
might  be  undertaken  with  success.  In  November,  1667,  some  months 
after  Denis's  case,  he  made  a  public  experiment  at  Arundel  House,  in 
which  twelve  ounces  of  sheep's  blood  were  injected  into  the  veins  of  a 
healthy  man,  who  is  stated  to  have  been  very  well  after  the  operation ; 
which  must  therefore  have  proved  successful.  These  nearly  simultane- 
ous cases  gave  rise  to  a  controversy  as  to  priority  of  invention  which 
was  long  carried  on  with  much  bitterness. 

The  idea  of  resorting  to  transfusion  after  severe  hemorrhage  does  not 
seem  to  have  been  then  entertained.  It  was  recommended  as  a  means 
of  treatment  in  various  diseased  states  or  with  the  extravagant  hope  of 
imparting  new  life  and  vigor  to  the  old  and  decrepit.  The  blood  of  the 
lower  animals  only  was  used ;  and  under  these  circumstances  it  is  not 
surprising  that  the  operation,  although  practised  on  several  occasions, 
was  never  established  as  it  might  have  been  had  its  indications  been 
better  understood. 

From  that  time  it  fell  almost  entirely  into  oblivion,  although  experi- 
ments and  suggestions  as  to  its  applicability  were  occasionally  made, 
especially  by  Dr.  Harwood,  Professor  of  Anatomy  at  Cambridge,  who 
published  a  thesis  on  the  subject  in  the  year  1785.  He,  however,  never 
carried  his  suggestions  into  practice,  and,  like  his  predecessors,  only  pro- 
posed to  employ  blood  taken  from  the  lower  animals.  In  the  year  1824, 
Dr.  Blundell  published  his  well-known  work  entitled  Researches,  Physio- 
logical and  Pathological,  which  detailed  a  large  number  of  experiments  ; 
and  to  that  distinguished  physician  belongs  the  undoubted  merit  of  hav- 
ing brought  the  subject  prominently  before  the  profession  and  of  pointing 
out  the  cases  in  which  the  operation  might  be  performed  with  hopes  of 
success.  Since  the  publication  of  this  work  transfusion  has  been  regarded 
as  a  legitimate  operation  under  special  circumstances;  but,  although  it 
has  frecjuently  been  performed  with  success,  and  in  spite  of  many  inter- 
esting monographs  on  the  subject,  it  has  never  become  so  established  as 
a  gent'i-al  n.'source  in  suitable  cases  as  its  advantages  would  seem  to  war- 
rant. Within  the  last  i'v.w  years  more  attention  has  been  ])aid  to  the 
subject,  and  tli(;  writings  of  Panum,  Martin,  and  I)(!  Pelina  abroad,  and 
of  Iligginson,  McDonnc.'ll,  Hicks,  Aveling,  and  8(;liafer  at  home,  amongst 
others,  have  thrown  much  light  on  many  jjoints  connected  with  the 
operation. 


536  OBSTETRIC  OPERATIONS. 

Nature  and  Object  of  the  Operation. — Transfusion  is  practically  only 
employed  in  cases  of  profuse  hemorrhage  connected  with  labor,  although 
it  has  been  suggested  as  possibly  of  value  in  certain  other  puerperal  con- 
ditions, such  as  eclampsia  or  puerperal  fever.  Theoretically,  it  m.ay  be 
expected  to  be  useful  in  such  diseases,  but,  inasmuch  as  little  or  nothing 
is  known  of  its  practical  effects  in  these  diseased  states,  it  is  only  possi- 
ble here  to  discuss  its  use  in  cases  of  excessive  hemorrhage.  Its  action 
is  probably  twofold  :  1st,  the  actual  restitution  of  blood  which  has  been 
lost ;  2d,  the  supply  of  a  sufficient  quantity  of  blood  to  stimulate  the 
heart  to  contraction,  and  thus  to  enable  the  circulation  to  be  carried  on 
until  fresh  blood  is  formed.  The  influence  of  transfusion  as  a  means  of 
restoring  lost  blood  must  be  trivial,  since  the  quantity  required  to  pro- 
duce an  eifect  is  generally  very  small  indeed,  and  never  sufficient  to 
counterbalance  that  which  has  been  lost.  Its  stimulant  action  is  no 
doubt  of  far  more  importance,  and  if  the  operation  be  performed  before 
the  vital  energies  are  entirely  exhausted  the  effect  is  often  most  marked. 

Use  of  Blood  taken  from  the  Loicer  Animals. — In  the  earliest  opera- 
tions the  blood  used  was  always  that  of  the  lower  animals,  generally  of 
the  sheep.  It  has  been  thought  by  Brown-Sequard  and  others  that  the 
blood  of  some  of  the  lower  animals,  especially  of  those  in  which  the  cor- 
puscles are  of  smaller  size  than  in  man,  as  of  the  sheep,  might  be  used 
with  safety,  provided  it  is  not  too  rich  in  carbonic  acid  and  too  poor  in 
oxygen,  and  injected  in  small  cpiantity  only.  Landois/  however,  has 
conclusi\'ely  proved  that  the  blood  of  aiiy  of  the  loA^^er  animals  has  a 
most  injurious  effect  on  the  human  red  corpuscles,  which  rapidly  become 
swollen  and  decolorized  and  discharge  their  coloring  matter  into  the 
serum.  It  is  certain,  therefore,  that  this  plan  cannot  be  adopted  in 
practice. 

Difficulties  from  Coagulcdion  of  Fibrin. — The  great  practical  difficulty 
in  transfusion  has  always  been  the  coagulation  of  the  blood  very  shortly 
after  it  has  been  removed  from  the  body.  When  fresh-drawn  blood  is 
exposed  to  the  atmosphere,  the  fibrin  commences  to  solidify  rapidly — 
generally  in  from  three  to  four  minutes,  sometimes  much  sooner.  It  is 
obvious  that  the  moment  fibrination  has  commenced  the  blood  is,  ipso 
facto,  unfitted  for  transfusion,  not  only  because  it  can  be  no  longer 
passed  readily  through  the  injecting  apparatus,  but  because  of  the  great 
danger  of  propelling  small  masses  of  fibrin  into  the  circulation  and  thus 
causing  embolism.  Hence,  if  no  attempt  be  made  to  prevent  this  diffi- 
culty, it  is  essential,  no  matter  what  apparatus  is  used,  to  hurry  on  the 
operation  so  as  to  inject  before  fibrination  has  begun.  This  is  a  fatal 
objection,  for  there  is  no  operation  in  the  whole  range  of  surgery  in 
which  calmness  and  deliberation  are  so  essential,  the  more  so  as  the  sur- 
roundings of  the  patient  in  these  unfortunate  cases  are  such  as  to  tax 
the  presence  of  mind  and  coolness  of  the  practitioner  and  his  assistants 
to  the  utmost. 

Methods  of  Obviating  Coagulation. — All  the  recent  improvements  have 
had  for  their  object  the  avoidance  of  coagulation  ;  and  practically  this  has 
been  effected  in  one  of  three  ways  :  1st,  by  immediate  transfusion  from 
arm  to  arm,  without  allowing  the  blood  to  be  exposed  to  the  atmosphere, 

^  Die  Transfusion  des  Blides,  Leii)sic,  1875. 


THE  TRANSFUSION  OF  BLOOD.  537 

according  to  the  methods  proposed  by  Aveling,  Roussel,  and  Schafer ; 
2d,  by  adding  to  the  blood  certain  chemical  reagents  which  have  the 
property  of  preventing  coagulation ;  3d,  removal  of  the  fibrin  entii-ely, 
by  promoting  its  coagulation  and  straining  the  blood,  so  that  the  liquor 
sanguinis  and  blood-corpuscles  alone  are  injected. 

Inasmuch  as  the  success  of  the  operation  altogether  depends  on  the 
method  adopted,  it  will  be  well,  before  going  farther,  to  consider  briefly 
the  advantages  and  disadvantages  of  each  of  these  plans. 

Immediate  Transfusion :  Aveling^ s  Method. — The  method  of  immediate  f 
transfusion  has  been  brought  promineiitly  before  the  profession  by  Dr.     l|;i,wwvti 
Aveling,  who  has  invented  an  ingenious  apparatus  for  performing  it.    (^„^^^,^ 
The  apparatus  consists  essentially  of  a  miniature  Higginson's  syringe     i     , . ' 

without  valves,  and   with   a   small  silver  canula  at  either  end.     One  i - 

canula  is  inserted  into  the  vein  of  the  person  supplying  blood,  the  other  ' 
into  a  vein  of  the  patient,  and  by  a  curious  manipulation  of  the  syringe, 
subsequently  to  be  described,  the  blood  is  carried  from  one  vein  into  the 
other.  It  must  be  admitted  that  if  there  were  no  practical  difficulties^; 
this  instrument  would  be  admirable ;  and  it  is  therefore  not  surprising 
that  it  should  have  met  with  so  much  favor  from  the  profession.  I  can- 
not but  think,  however,  that  the  operation  is  not  so  simple  as  at  first  sight 
appears,  and  that  therefore  it  wants  one  of  the  essential  elements  required 
in  any  procedure  for  performing  transfusion.  One  of  my  objections  is 
that  it  is  by  no  means  easy  to  work  the  apparatus  without  considerable 
practice.  Of  this  I  have  satisfied  myself  by  asking  members  of  my  class 
to  work  it  after  reading  the  printed  directions,  and  finding  that  they  are 
not  always  able  to  do  so  at  once.  Of  course  it  may  be  said  that  it  is 
easy  to  acquire  the  necessary  manipulative  skill;  but  when  the  necessity 
for  transfusion  arises  there  is  no  time  left  for  practising  with  the  instru- 
ment, and  it  is  essential  that  an  apparatus  to  be  universally  applicable 
should  be  capable  of  being  used  immediately  and  without  previous 
experience.  Other  objections  are  the  necessity  of  several  assistants, 
the  uncertainty  of  there  being  a  sufficient  circulation  of  blood  in  the 
veins  of  the  donor  to  aiford  a  constant  supply,  and  the  possibility  of  the 
whole  apparatus  being  disturbed  by  restlessness  or  jactitation  on  the 
part  of  the  patient.  For  these  reasons  it  seems  to  me  that  this  plan  of 
immediate  transfusion  is  not  so  simple  nor  so  generally  applicable  as 
defibrination.  Still,  it  is  impossible  not  to  recognize  its  merits,  and  it  is 
certainly  well  worthy  of  further  study  and  investigation. 

liousseVs  Method. — Another  method  of  immediate  transfusion  is  that 
recommended  by  Roussel,'  whose  apparatus  has  recently  attracted  con-  ' 
sideral)le  attention.  It  possesses  many  undoubted  advantages,  and  is, 
beyond  doubt,  a  valuable  addition  to  our  means  of  performing  the  ope- 
ration. It  has,  however,  the  great  disadvantage  of  being  costly  and  com- 
l)licated,  and  hence  I  do  not  believe  that  it  is  likely  to  come  into  general 
use. 

fSchdfer's  Method. — The  third  method  is  that  recommended  by  Dr.       ' 
.Scliilfer  in  his  recent  excellent  reports  on  transfusion  submitted  to  the 
Ohstetri(;al  Society.^     S(!hafer  suggests  two  methods  of  performing  the 
operation — one  from  vein  to  vein,  the  other  from  artery  to  artery.     The 

^  Obstetrical  TransaciionH,  vol.  xviii.  ^  Ibid.,  vol.  xxi. 


538  OBSTETRIC  OPERATIONS. 

latter,  he  holds,  has  the  advantage  of  supplying  pure  oxygenated  blood 
under  the  best  possible  conditions  for  securing  the  amelioration  of  a 
patient  suifering  from  the  effects  of  profuse  hemorrhage.  The  necessary 
operative  proceedings  are,  however,  somewhat  complicated,  and  it  seems 
to  me  very  doubtful  if  this  plan  is  likely  to  be  at  all  commonly  used. 
His  method  of  immediate  transfusion,  however,  is  very  simple,  and  is 
well  worthy  of  trial.  In  his  experiments  on  the  lower  animals  it  an- 
swered admirably.  I  am  not  aware  that  it  has  yet  been  tried  on  tlie 
human  subject,  but  I  do  not  see  any  practical  difficulty  in  its  applica- 
tion. For  the  description  of  the  operation  I  have  inserted  Dr.  Sclijifer's 
own  directions  for  the  performance  of  both  arterial  and  venous  imme- 
diate transfusion. 

Addition  of  Chemical  Agents  to  Prevent  Coagulation. — The  second 
plan  for  obviating  the  bad  effects  of  clotting  is  the  addition  of  some 
substance  to  the  blood  which  shall  prevent  coagulation.  It  is  well 
known  that  several  salts  have  this  property,  and  the  experiments  made 
in  the  case  of  cholera  patients  prove  that  solutions  of  some  of  them  may 
be  injected  into  the  venous  system  without  injury.  This  method  has 
been  specially  advocated  by  Dr.  Braxton  Hicks,  who  uses  a  solution  of 
three  ounces  of  fresh  phosphate  of  soda  in  a  pint  of  water,  about  six 
ounces  of  which  are  added  to  the  quantity  of  blood  to  be  injected.  He 
has  narrated  4  cases  ^  in  which  this  plan  was  adopted  successfully,  so  far 
as  the  prevention  of  coagulation  was  concerned.  It  certainly  enables  the 
operation  to  be  performed  with  deliberation  and  care,  but  it  is  somewhat 
complicated  ;  and  it  may  often  happen  that  the  necessary  chemicals  are 
not  at  hand.  A  further  objection  is  the  bulk  of  fluid  which  must  be 
injected ;  and  there  is  reason  to  believe  that  this  has  in  some  cases  seri- 
ously embarrassed  the  heart's  action  and  interfered  with  the  success  of 
the  operation.  In  many  of  the  successful  cases  of  transfusion  the  amount 
of  blood  injected  has  been  very  small,  not  more  than  two  ounces.  Dr. 
Richardson  proposes  to  prevent  coagulation  by  the  addition  of  liquor 
ammonite  to  the  blood,  in  the  proportion  of  two  minims  diluted  with 
twenty  minims  of  water  to  each  ounce  of  blood. 

Defibrination  of  the  Blood. — The  last  method,  and  the  one  which,  on 
the  whole,  I  believe  to  be  the  simplest  and  most  effectual,  is  defibrina- 
tion. It  has  been  chiefly  practised  in  this  country  by  Dr.  McDonnell 
of  Dublin,  who  has  published  several  very  interesting  cases  in  which  he 
employed  it,  and  abroad  by  Martin  of  Berlin  and  De  Belina  of  Paris. 
The  process  of  removing  the  fibrin  is  simple  in  the  extreme,  and  occu- 
pies a  few  minutes  only.  Another  advantage  is  that  the  blood  to  be 
transfused  may  be  prepared  quietly  in  an  adjoining  apartment,  so  that 
the  operation  may  be  performed  with  the  greatest  calmness  and  delibera- 
tion, and  the  donor  is  spared  the  excitement  and  distress  which  the  sight 
of  the  apparently  moribund  patient  is  apt  to  cause,  and  which,  as  Dr. 
Hicks  has  truly  pointed  out,  may  interfere  with  the  free  flow  of  blood. 
The  researches  of  Panum,  Brown-Sequard,  and  others  have  proved  that 
the  blood-corpuscles  are  the  true  vivifying  element,  and  that  defibrinated 
blood  acts  as  well,  in  every  respect,  as  that  containing  fibrin.  It  has 
been  proved  that  the  fibrin  is  reproduced  within  a  short  time,^  and  the 
^  Guy's  Hospital  Repoi'ts,  vol.  xiv.  ^  Panum,  Virchorv's  Arch.,  vol.  xxvii. 


THE  TRANSFUSION  OF  BLOOD.  539 

whole  tendency  of  modern  research  is  to  regard  it  not  as  an  essential  ele- 
ment of  the  blood,  but  as  an  excrementitious  product,  resulting  from  the 
degradation  of  tissue  ;  which  may  therefore  be  advantageously  removed. 
Another  advantage  derived  from  defibrination  is,  that  the  corpuscles  are 
freely  exposed  to  the  atmosphere,  oxygen  is  taken  up,  and  carbonic  acid 
given  off,  and  the  dangers  which  Brown-Sequard  has  shown  to  arise 
from  the  use  of  blood  containing  too  much  carbonic  acid  are  thereby 
avoided.  There  can  be,  therefore,  no  physiological  objection  to  the 
removal  of  the  fibrin,  which,  moreover,  takes  away  all  practical  difficul- 
ty from  the  operation.  The  straining  to  which  the  defibrinated  blood  is 
subjected  entirely  prevents  the  possibility  of  even  the  most  minute  par- 
ticle of  fibrin  being  contained  in  the  injected  fluid ;  the  risk  from  embo- 
lism is  therefore  less  than  in  any  of  the  other  processes  already  referred 
to.  My  own  experience  of  this  plan  is  limited  to  3  cases,  but  in  2  it 
answered  so  well  that  I  can  conceive  no  reasonable  objection  to  it.  I 
should  be  inclined  to  say  that  transfusion,  thus  performed,  is  amongst 
the  simplest  of  surgical  operations — an  opinion  which  the  experience  of 
McDonnell  and  others  fully  confirms. 

Transfusion  of  Milk. — Recently  the  intra-venous  injection  of  freshly- 
drawn  warm  milk  has  been  recommended  as  a  substitute  for  blood, 
chiefly  in  America.  It  was  first  used  by  Dr.  Hodder  of  Toronto,  but 
has  been  introduced  and  strongly  advocated  by  Thomas  of  New  York, 
who  has  used  it  twice  after  ovariotomy.  Brown-Sequard  in  experi- 
menting on  the  lower  animals  found  that  it  answered  as  well  as  either 
fresh  or  defibrinated  blood,  and  about  half  an  hour  after  the  injection 
no  trace  of  the  milk-corpuscles  could  be  found  in  the  blood.  Schafer, 
however,  found  that  the  action  of  milk  on  the  blood-corpuscles  wa3 
highly  deleterious,  and  that  it  introduces  the  germs  of  septic  organisms 
likely  to  produce  very  serious  results.  He  therefore  pronounces  strongly 
against  its  use. 

Statistical  Results. — The  number  of  cases  of  transfusion  are  perhaps 
not  sufficient  to  admit  of  completely  reliable  conclusions.  It  is  certain, 
however,  that  transfusion  has  often  been  the  means  of  rescuing  the 
patient  wlien  apparently  at  tlie  point  of  death  and  after  all  other  mean? 
of  treatment  had  failed.  Professor  Martin  records  57  cases,  in  43  of 
which  transfusion  was  completely  successful,  and  in  7  temporarily  so, 
while  in  the  remaining  7  no  reaction  took  place.  Dr.  Higginson  of 
Liverpool  has  had  15  cases,  10  of  which  were  successful.  Figures  such 
as  these  are  encouraging,  and  they  are  sufficient  to  prove  that  the  oj^era- 
tion  is  one  which  at  least  offiirs  a  fair  hope  of  success,  and  which  no 
obstetrician  would  be  justified  in  neglecting  when  the  patient  is  sinking 
from  the  exhaustion  of  profuse  hemorrhage.  It  is  to  be  hoped  also 
that  further  experience  may  })rove  it  to  be  of  value  in  other  cases  in. 
which  its  use  has  been  suggested,  but  not,  as  yet,  put  to  the  test  of 
experiment. 

Possilde  Dangers  of  the  Operation. — The  possible  risks  of  the  ojiera- 
tion  would  seem  to  be  tlio  danger  of  injecting  minute  ])articles  of  fibrin 
which  form  emboli,  of  bubbles  of  air,  or  of  overwhelming  the  action  of 
the  heart  by  injef;ting  too  raj)idly  or  in  too  great  quantity.  These  may 
be,  to  a  great  extent,  prevented  by  careful  attention  to  the  proper  per- 


540  OBSTETRIC  OPERATIONS. 

formance  of  the  operation,  and  it  does  not  clearly  appear  from  the 
recorded  cases  that  they  have  ever  proved  fatal.  AVe  must  also  bear  in 
mind  that  transfusion  is  seldom  or  never  likely  to  be  attempted  until 
the  patient  is  in  a  state  which  would  otherwise  almost  certainly  preclude 
the  hope  of  recovery,  and  in  which,  therefore,  much  more  hazardous 
proceedings  M'ould  be  fully  justified. 

Cases  Suitable  for  Transfusion. — The  cases  suitable  for  transfusion  are 
those  in  which  the  patient  is  reduced  to  an  extreme  state  of  exhaustion 
from  hemorrhage  during  or  after  labor  or  miscarriage,  whether  by  the 
repeated  losses  of  placenta  previa  or  the  more  sudden  and  profuse  flood- 
/^ing  of  post-partum  hemorrhage.  The  operation  will  not  be  contem- 
plated until  other  and  simpler  means  have  been  tried  and  failed,  or  until 
the  symptoms  indicate  that  life  is  on  the  verge  of  extinction.  If  the 
patient  should  be  deadly  pale  and  cold,  with  no  pulse  at  the  wrist  or  one 
that  is  scarcely  perceptible ;  if  she  be  unable  to  swallow,  or  vomits 
incessantly  ;  if  she  lie  in  an  unconscious  state ;  if  jactitation  or  convul- 
sions or  repeated  fainting  should  occur ;  if  the  respiration  be  laborious 
or  very  rapid  and  sighing  ;  if  the  pupil  do  not  act  under  the  influence 
of  light, — it  is  evident  that  she  is  in  a  condition  of  extreme  danger,  and 
it  is  under  such  circumstances  that  transfusion,  performed  sufficiently 
soon,  offers  a  fair  prospect  of  success.  It  does  not  necessarily  follow 
because  one  or  other  of  these  symptoms  is  present  that  there  is  no  chance 
of  recovery  under  ordinary  treatment,  ancl'incleed  it  is  within  the  expe- 
rience of  all  that  patients  have  rallied  under  apparently  the  most  hope- 
less conditions.  But  when  several  of  them  occur  together  the  prospect 
of  recovery  is  much  diminished,  and  transfusion  would  then  be  fully 
justified,  especially  as  there  is  no  reason  to  think  that  a  fatal  result  has 
ever  been  directly  traced  to  its  employment.  Indeed,  like  most  other 
obstetric  operations,  it  is  more  likely  to  be  postponed  until  too  late  to  be 
of  good  service  than  to  be  employed  too  early ;  and  in  some  of  the  cases 
reported  as  unsuccessful  it  was  not  performed  until  respiration  had 
ceased  and  death  had  actually  taken  place.  It  has  sometimes  been  said 
that  transfusion  should  never  be  employed  if  the  uterus  be  not  firmly 
contracted,  so  as  to  prevent  the  injected  blood  again  making  its  escape 
through  the  uterine  sinuses.  The  cases  in  which  this  is  likely  to  occur 
are  few ;  and  if  one  were  met  with  the  escape  of  blood  could  be  pre- 
vented by  the  injection  into  the  uterus  of  the  perchloride  of  iron. 

Description  of  the  Operation. — In  describing  the  operation  I  shall 
limit  myself  to  an  account  of  Aveling's  and  Schafer's  method  of  imme- 
diate transfusion  and  to  that  of  injecting  defibrinated  blood.  I  consider 
myself  justified  in  omitting  any  account  of  the  numerous  instruments 
wiiich  have  been  invented  for  the  purpose  of  injecting  pure  blood,  since 
I  believe  the  practical  difficulties  are  too  great  ever  to  render  this  form 
of  operation  serviceable.  The  great  objection  to  most  of  them  is  their 
cost  and  complexity,  and  as  long  as  any  special  apparatus  is  considered 
essential  the  full  benefits  to  be  derived  from  transfusion  are  not  likely 
to  be  realized.  The  necessity  for  employing  it  arises  suddenly  ;  it  may 
be  in  a  locality  in  which  it  is  impossible  to  procure  a  special  instru- 
ment ;  and  it  would  be  M-ell  if  it  were  understood  that  transfusion  may 
be  safely  and  effectually  performed  by  the  simplest  means.     In  many 


THE  TRANSFUSION  OF  BLOOD. 


541 


of  the  successful  cases  an  ordinary  syringe  was  used ;  in  one,  in  the 
absence  of  other  instruments,  a  child's  toy  syringe  was  employed.  I 
have  myself  performed  it  with  a  simple  syringe  purchased  at  the  near- 
est chemist's  shop  when  a  special  transfusion  apparatus  failed  to  act  sat- 
isfactorily. 

Method  of  Performing  Immediate  Transfusion. — In  immediate  trans- 
fusion (Fig.  190)  the  donor  is  seated  close  to  the  patient,  and  the  veins 

Fig.  190. 


Method  of  Transfusion  by  Aveling's  Apparatus. 

in  the  arms  of  each  having  been  opened,  the  silver  canula  at  either  end 
of  the  instrument  is  introduced  into  them  (a  b).  The  tube  between  the 
bulb  and  the  donor  is  now  pinched  (d),  so  as  to  form  a  vacuum,  and  the 
bulb  becomes  filled  with  blood  from  the  donor.  The  finger  is  now 
removed  so  as  to  compress  the  distal  tube  (d'),  and,  the  bulb  being  com- 
pressed (c),  its  contents  are  injected  into  the  patient's  vein.  The  bulb 
is  calculated  to  hold  about  two  drachms,  so  that  the  amount  injected  can 
be  estimated  by  the  number  of  times  it  is  emptied.  The  risk  of  inject- 
ing air  is  prevented  by  filling  the  syringe  with  water,  which  is  injected 
before  the  blood. 

Schdfer^s  Directions  for  Immediate  Transfusion. — "  Procure  two  glass 
canulas  of  appropriate  size  and  shape  (see  Fig.  191),  and  a  piece  of  black 
india-rubber  tubing  seven  inches  long  and  not  less  than  a 
quarter  of  an  inch  bore,  fitted  to  the  canulas.  This  appara- 
tus could  always  be  improvised. 

Proceditre. — "  Place  the  transfusion-tube  in  a  basin  of 
hot  water  containing  a  little  carbonate  of  soda.  Put  a 
tape  round  the  arm  of  the  patient  just  below  the  place 
where  the  vein  is  to  be  opened  and  another  just  above. 
Expose  the  vein  by  an  incision  througli  the  skin,  which 
should  be  made  transversely  if  tlie  position  of  the  vein 
cannot  be  made  out  through  the  slcin.  Clear  a  small 
piece  of  the  vein  with  forceps  and  slij)  a  pointed  piece  of 
card  underneath  it.  By  a  snip  witli  scissors  make  an 
oblique  opening  into  the  vein,  and  partly  insert  a  small 
blunt  instrument  (such  as  a  wool-needle),  so  that  the  aper- 
ture is  not  lost.    Remove  the  upper  tajie.    Next  prepare  the  vein  of  the 


Fig.  191. 


542  OBSTETRIC  OPERATIONS. 

giver.  To  do  this  put  tapes  around  the  arm  just  below  and  above  the 
place  where  the  vein  is  to  be  opened.  Expose  the  vein  by  a  longitudinal 
incision  through  the  skin.  Clear  a  small  piece  of  the  vessel  \\'\\\\  for- 
ceps and  pass  a  thread  ligature  underneath.  A  slip  of  card  may  also  be 
placed  under  this  vein.  Make  a  snip  into  the  vein  just  above  the  liga- 
ture, and  then,  taking  the  transfusion-tube  out  of  the  soda  solution,  slip 
one  of  the  canulas  into  the  vein  of  the  giver,  and  tie  it  in  with  a  simjile 
knot  which  can  be  readily  untied.  Let  the  giver  go  to  the  bedside  and 
place  his  arm  alongside  that  of  the  patient.  Hold  the  end  of  the  india- 
rubber  tube  with  the  second  canula  up  a  little,  and  release  the  lower 
tape  on  the  arm  of  the  blood-giver.  As  soon  as  blood  flows  out  of 
the  second  canula  pinch  the  india-rubber  tube  close  to  the  canula, 
so  as  to  stop  the  flow,  and,  removing  the  wool-needle,  slip  the  end 
of  the  canula  into  the  vein  of  the  patient,  hold  it  there,  and  allow 
the  blood  to  pass  freely  along  the  tube.  Three  minutes  will  generally 
be  long  enough  for  the  flow,  which  can  be  stopped  by  compressing 
the  vein  of  the  giver  below  the  canula.  Both  canulas  may  now  be 
withdrawn  and  the  ligature^  removed  from  the  vein  of  the  giver,  the 
cut  veins  being  dealt  with  in  the  usual  way.  Of  course  the  other  tape 
on  the  arm  of  the  donor  must  be  removed  as  soon  as  the  transfusion 
is  over. 

"  Instead  of  using  the  transfusion-tube  empty,  it  may  be  filled  with 
soda  solution,  to  the  exclusion  of  air.  It  is  necessary  to  have  one  or 
two  spring  clips  on  the  tube  to  prevent  the  escape  of  the  solution.  This 
is  a  much  better  plan  than  the  other,  for  the  blood  need  not  be  allowed 
to  flow  into  the  tube  until  the  second  canula  is  inserted,  and  then,  by 
opening  the  clips,  it  may  drive  the  soda  solution  before  it  into  the  vein. 
The  small  quantity  of  carbonate-of-soda  solution  necessary  to  fill  the 
simple  tube  will  do  the  patient  no  harm. 

Direct  Centripetal  Arterial  Transfusion. — "  In  the  first  place,  we  have 
to  determine  what  artery  or  arteries  would  be  most  available  for  the  pur- 
pose. The  (left)  radial  artery  could  be  most  easily  dealt  with,  and  its 
use  would  involve  less  subsequent  inconvenience  to  the  donor  of  the 
blood  than  any  other.  But  if  it  is  considered  necessary  to  choose  some 
other  artery,  t  think  the  dorsal  artery  of  the  foot  should  be  selected,  for 
its  employment  presents  several  advantages.  It  is  a  minor  artery,  but 
nevertheless  large  enough  for  the  insertion  of  a  canula;  it  is  compara- 
tively superficial  and  pretty  easily  found ;  and  by  causing  the  person 
yielding  the  blood  to  stand  up  a  great  amount  of  pressure  may  be 
obtained  in  it.  In  the  bloodless  patient,  especially  if  there  be  much 
subcutaneous  fat,  this  artery  might  not  be  readily  found. 

Apparatus  Required. — "A  piece  of  india-rubber  tubing  six  or  seven 
inches  long,  two  glass  canulas  of  appropriate  size  and  shape,  and  some 
spring  clips,  two  of  which  should  be  small  for  compressing  the  arteries, 
the  others  larger  and  adapted  for  clipping  the  tube.  The  smaller  clips 
might  be  dispensed  with,  and  ligatures  fastened  with  a  slip  bow  might 
be  used  instead,  in  the  way  Lower  recommended.  Before  commencing 
it  is  important  to  ensure  that  the  india-rubber  tube  cannot  slip  ofP_  the 
canulas.  It  ought  to  be  secured  to  them  by  tight  ligatures  or  by  bind- 
ing wire.    This  precaution  is  necessary  because  the  arterial  blood  is  under 


THE  TRANSFUSION  OF  BLOOD.  543 

considerable  pressure.  This  would  tend  to  force  the  tubes  apart  and 
might  cause  copious  hemorrhage. 

"  The  transfusion-tube  is  to  be  placed  as  before  in  carbonate-of-soda 
solution. 

Procedure. — "  The  artery  of  the  patient  must  first  be  exposed.  To  do 
this  make  an  incision  an  inch  in  length  through  the  skin  over  the  line 
of  the  artery,  and  then  divide  to  an  equal  extent  the  subcutaneous  tissue 
and  fascia  which  cover  it.  About  three-quarters  of  an  inch  in  length 
of  the  vessel  is  to  be  separated  from  the  ensheathing  connective  tissue 
and  from  its  accompanying  veins  by  slipping  a  blunt  instrument,  such 
as  an  aneurism-needle  or  the  blade  of  a  forceps,  underneath  and  moving 
it  up  and  down.  A  small  piece  of  card,  cut  into  a  long  triangular  shape, 
may  then  be  placed  under  instead  of  the  needle.  A  ligature  is  then  tied 
tightly  around  the  lower  end  of  the  piece  of  artery,  another  is  looped 
loosely  around  the  middle,  and  a  spring  clip  is  put  on  close  to  the  upper 
end.  The  vessel  may  now  be  opened  just  above  the  lower  ligature  by  a 
snip  with  the  scissors. 

"  If  the  artery  have  any  branch  at  the  exposed  part,  this  ought  to  be 
tied  before  commencing  to  isolate  the  vessel.  In  the  person  mIio  is  to 
yield  the  blood  exactly  the  same  process  is  carried  out. 

"  The  transfusion-tube  is  next  filled  (by  suction)  with  soda  solution, 
and  this  is  prevented  from  escaping  by  one  or  two  spring  clips  on  the 
tube. 

"  One  of  the  glass  terminals  is  tied  into  the  artery  of  the  giver  and 
the  other  into  the  artery  of  the  patient,  the  ends  of  both  behigjlirected 
toward  the  heart. 

"All  is  now  ready  for  the  transfusion.  To  effect  this,  remove  the  clips 
on  the  india-rubber  tube  and  open  the  clip  on  the  artery  of  the  patient ; 
then  open — not  remove — that  on  the  artery  of  the  giver,  and  keep  it 
open  one  minute,  or  a  little  longer  if  it  seems  advisable.  Allow  the  clips 
to  close  again,  and  if  the  patient's  condition  is  ameliorated  the  operation 
may  be  ended  by  tying  the  arteries — first  that  of  the  giver,  then  that  of 
the  patient — -just  above  the  clips. 

"  Finally,  cut  out  and  remove  the  canulas,  together  with  the  pieces  of 
artery  into  which  they  are  tied." 

Iiijed'ion  of  Defibrinated  Blood. — For  injecting  defibrinated  blood 
various  contrivances  have  been  used.  McDonnell's  instrument  is  a  sim- 
ple cylinder  with  a  nozzle  attached,  from  which  the  blood  is  propelled 
by  gravitation.  When  the  propulsive  poAver  is  insufficient,  increased 
pressure  is  applied  by  breaking  forcibly  into  the  open  end  of  the  receiver. 
De  Belina's  instrument  is  on  the  same  principle,  only  atmospheric  pres- 
sure is  supplied  by  a  contrivance  similar  to  Richardson's  spray-producer, 
attached  to  one  end.  The  idea  is  simple,  but  there  is  some  doubt  of  a 
gravitation  instrument  being  sufficiently  powerful,  and  it  certainly  failed 
in  my  hands.  I  have  had  valves  applied  to  Aveling's  instrument,  so 
that  it  works  by  compression  of  the  bulb  like  an  ordinary  Higginson's 
syringe.  This,  with  a  single  silver  canula  at  one  end  for  introduction 
into  the  vein,  forms  a  perfect  and  inexpensive  transfusion-apparatus, 
taking  up  scarcely  any  space.  If  it  be  not  at  hand,  any  small  syringe 
with  a  tolerably  fine  nozzle  may  be  used. 


544  OBSTETRIC  OPERATIONS. 

Mode  of  Preparing  the  Blood, — The  first  step  of  the  operation  is 
defibrination  of  tlie  blood,  which  should,  if  possiblp,  be  prepared  in  an 
apartment  adjoining  the  patient's.  The  blood  should  be  taken  from  the 
arm  of  a  strong  and  healthy  man.  The  quality  cannot  be  unimportant, 
and  in  some  recorded  cases  the  failure  of  the  operation  has  been  attrib- 
uted to  the  fact  of  the  donor  having  been  a  weakly  female.  The  sup- 
ply from  a  woman  might  also  prove  insufficient ;  and,  although  it  has 
been  shown  that  blood  from  two  or  more  persons  may  be  used  Mith 
safety,  yet  such  a  change  necessarily  causes  delay,  and  should,  if  possi- 
ble, be  avoided.  A  vein  having  been  opened,  eight  or  ten  ounces  of 
blood  are  withdrawn,  and  received  into  some  perfectly  clean  vessel,  such 
as  a  dessert  finger-glass.  As  it  flows  it  should  be  briskly  agitated  with 
a  clean  silver  fork  or  a  glass  rod,  and  very  shortly  strings  of  fibrin 
begin  to  form.  It  is  now  strained  through  a  piece  of  fine  muslin,  previ- 
ously dipped  in  hot  water,  into  a  second  vessel  which  is  floating  in 
w^ater  at  a  temperature  of  about  105°.  By  this  straining  the  fibrin  and 
all  air-bubbles  resulting  from  the  agitation  are  removed,  and  if  there 
be  no  excessive  hurry  it  might  be  well  to  repeat  the  straining  a  second 
time.  If  the  vessel  be  kept  floating  in  warm  water,  the  blood  is  pre- 
vented from  getting  cool,  and  we  can  now  proceed  to  prepare  the  arm  of 
the  patient  for  injection. 

Mode  of  Exposing  the  Veins  selected  for  Transfusion. — This  is  the 
most  delicate  and  difficult  part  of  the  operation,  since  the  veins  are  gen- 
erally collapsed  and  empty  and  by  no  means  easy  to  find.  The  best  way 
of  exposing  them  is  that  practised  by  McDonnell,  who  pinches  up  a  fold 
of  the  skin  at  the  bend  of  the  elbow,  and  transfixes  it  with  a  fine  tenot- 
omy-knife  or  scalpel,  so  making  a  gaping  wound  in  the  integument,  at 
the  bottom  of  which  they  are  seen  lying.  A  probe  should  now  be  passed 
underneath  the  vein  selected  for  opening,  so  as  to  avoid  the  chance  of  its 
being  lost  at  any  subsequent  stage  of  the  operation.  This  is  a  point  of 
some  importance,  and  from  the  neglect  of  this  precaution  I  have  been 
obliged  to  open  another  vein  than  that  originally  fixed  on.  A  small 
portion  of  the  vein  being  raised  with  the  forceps,  a  nick  is  made  into  it 
for  the  passage  of  the  canula. 

Injection  of  the  Blood. — The  prepared  blood  is  now  brought  to  the 
bedside,  and,  the  apparatus  having  been  previously  filled  with  blood  to 
avoid  the  risk  of  injecting  any  bubbles  of  air,  the  canula  is  inserted  into 
the  opening  made  in  the  vein  and  transfusion  commenced.  It  should  be 
constantly  borne  in  mind  that  this  part  of  the  operation  should  be  con- 
ducted with  the  greatest  caution,  the  blood  introduced  very  slowly,  and 
the  effect  on  the  patient  carefully  watched.  The  injection  may  be  pro- 
ceeded with  until  some  perceptible  effect  is  produced,  which  will  gener- 
ally be  a  return  of  the  pulsation,  first  at  the  heart,  and  subsequently  at 
the  wrist,  an  increase  in  the  temperature  of  the  body,  greater  depth  and 
frequency  of  the  respirations,  and  a  general  appearance  of  returning 
animation  about  the  countenance.  Sometimes  the  arms  have  been 
thrown  about  or  spasmodic  twitchings  of  the  face  have  taken  place. 
The  quantity  of  blood  required  to  produce  these  effects  varies  greatly, 
but  in  the  majority  of  cases  has  been  very  small.  Occasionally  2 
ounces  have  proved  sufficient,  and  the  average  may  Le  taken  as  ranging 


THE  TRANSFUSION  OF  BLOOD.  545 

between  4  and  6,  although  in  a  few  cases  between  10  and  20  have  been 
used.  The  practical  rule  is  to  proceed  very  slowly  with  the  injection 
until  some  perceptible  result  is  observed.  Should  embarrassed  or  fre- 
quent respiration  supervene,  we  may  suspect  that  we  have  been  injecting 
either  too  great  a  quantity  of  blood  or  with  too  much  force  and  rapidity, 
and  the  operation  should  at  once  be  suspended,  and  not  resumed  until 
the  suspicious  symptoms  have  passed  away.  It  may  happen  that  the 
eifects  of  the  transfusion  have  been  highly  satisfactory,  but  that  in  the 
course  of  time  there  is  evidence  of  returning  syncope.  This  may  possi- 
bly be  prevented  by  the  administration  of  stimulants,  but  if  these  fail 
there  is  no  reason  why  a  fresh  supply  of  blood  should  not  again  be 
injected,  but  this  should  be  done  before  the  effects  of  the  first  transfusion 
have  entirely  passed  away. 

Secondary  Effects  of  Transfusion. — The  subsequent  effects  in  success- 
ful cases  of  transfusion  merit  careful  study.  In  some  few  cases  death  is 
said  to  have  happened  within  a  few  weeks  with  symptoms  resembling 
pyaemia.  Too  little  is  known  on  this  point,  however,  to  justify  any 
positive  conclusions  with  regard  to  it. 

35 


PART  y, 

THE  PUERPERAL  STATE. 


CHAPTER   I. 

THE  PUEEPEEAL  STATE  AND  ITS  MANAGEMENT. 

Importance  of  Studying  the  Puerperal  State. — The  key  to  the  manage- 
ment of  women  after  labor,  and  to  the  proper  understanding  of  the  many- 
important  diseases  which  may  then  occur,  is  to  be  found  in  a  study  of 
the  phenomena  following  delivery  and  of  the  changes  going  on  in  the 
mother's  system  during  the  puerperal  period.  No  doubt  natural  labor 
is  a  physiological  and  healthy  function,  and  during  recovery  from  its 
effects  disease  should  not  occur.  It  must  not  be  forgotten,  however, 
that  none  of  our  patients  are  under  physiologically  healthy  conditions. 
The  surroundings  of  the  lying-in  woman,  the  effects  of  civilization,  of 
errors  of  diet,  of  defective  cleanliness,  of  exposure  to  contagion,  and  of 
a  hundred  other  conditions  which  it  is  impossible  to  appreciate,  have 
most  important  influences  on  the  results  of  childbirth.  Hence  it  follows 
that  labor,  even  under  the  most  favorable  conditions,  is  attended  with 
considerable  risk. 

The  Mortality  of  Childbirth. — It  is  not  easy  to  say  with  accuracy  what 
is  the  precise  mortality  accompanying  childbirth  in  ordinary  domestic 
practice,  since  the  returns  derived  from  the  reports  of  the  Registrar- 
General  or  from  private  sources  are  manifestly  open  to  serious  error. 
The  nearest  approach  to  a  reliable  estimate  is  that  made  by  Dr.  Mat- 
thews Duncan,^  who  calculates,  from  figures  derived  from  various  sources, 
that  no  fewer  than  1  out  of  every  120  women,  delivered  at  or  near  the 
full  time,  dies  within  four  weeks  of  childbirth.  This  indicates  a  mor- 
tality far  above  that  which  has  been  generally  believed  to  accompany 
childbearing  under  favorable  circumstances.  It,  however,  closely  ap- 
proximates to  a  similar  estimate  made  by  McClintock,^  who  calculates 
the  mortality  in  England  and  Wales  as  1  in  126,  and  in  the  upper  and 
middle  classes  alone,  where  the  conditions  may  naturally  be  supposed  to 
be  more  favorable,  at  1  in  1 46  ;  more  recently  he  has  come  to  the  con- 
clusion, from  his  own  increased  experience  and  the  published  results  of 
the  practice  of  others,  that  1  in  100  would  more  correctly  represent  the 
rate  of  puerperal  mortality.^  In  these  calculations  there  are  some  obvi- 
ous sources  of  error,  since  they  include  deaths  from  all  causes  within 

1  The  "  Mortality  of  Childbed,"  Edin.  Med.  Journ.,  Nov.,  1869. 

2  Dublin  Quarterly  Journ.,  Aug.,  1869.  ^  Brit.  Med.  Journ.,  Aug.  10,  1878. 

546 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.  547 

four  weeks  of  delivery,  some  of  which  must  have  been  independent  of 
the  puerperal  state. 

But  it  is  not  the  deaths  alone  which  should  be  considered.  All  prac- 
titioners know  how  large  a  number  of  their  patients  suffer  from  morbid 
states  which  may  be  directly  traced  to  the  effects  of  childbearing.  It  is 
impossible  to  arrive  at  any  statistical  conclusion  on  this  point,  but  it 
must  have  a  very  sensible  and  important  influence  on  the  health  of 
childbearing  women. 

Alterations  in  the  Blood  after  Delivery. — The  state  of  the  blood  during 
pregnancy,  already  referred  to  (p.  140),  has  an  important  bearing  on  the 
puerperal  state.  There  is  hyperinosis,  which  is  largely  increased  by  the 
changes  going  on  immediately  after  the  birth  of  the  child  ;  for  then  the 
large  supply  of  blood  which  has  been  going  to  the  uterus  is  suddenly 
stopped,  and  the  system  must  also  get  rid  of  a  quantity  of  effete  matter 
thrown  into  the  circulation  in  consequence  of  the  degenerative  changes 
occurring  in  the  muscular  fibres  of  the  uterus.  Hence  all  the  depura- 
tive  channels  by  which  this  can  be  eliminated  are  called  on  to  act  with 
great  energy.  If,  in  addition,  the  peculiar  condition  of  the  generative 
tract  be  borne  in  mind — viz.  the  large  open  vessels  on  its  inner  surface, 
the  partially  bared  inner  surface  of  the  uterus,  and  the  channels  for 
absorption  existing  in  consequence  of  slight  lacerations  in  the  cervix  or 
vagina — it  is  not  a  matter  of  surprise  that  septic  diseases  should  be  so 
common. 

Condition  after  Delivery. — It  will  be  well  to  consider  successively  the 
various  changes  going  on  after  delivery,  and  then  we  shall  be  in  a  better 
position  for  studying  the  rational  management  of  the  puerperal  state. 

Nervous  Shock. — Some  degree  of  nervous  shock  or  exhaustion  is  ob- ,, 
servable  after  most  labors.  In  many  cases  it  is  entirely  absent,  in  others  \ 
it  is  well  marked.  Its  amount  is  in  proportion  to  the  severity  of  the 
labor  and  the  susceptibility  of  the  patient ;  and  it  is  therefore  most  likely 
to  be  excessive  in  women  who  have  suffered  greatly  from  pain,  who  have 
undergone  much  muscular  exertion,  or  who  have  been  weakened  from 
undue  loss  of  blood.  It  is  evidenced  by  a  feeling  of  exhaustion  and 
fatigue,  and  not  uncommonly  there  is  some  shivering,  which  soon  passes 
off,  and  is  generally  followed  by  refreshing  sleep.  The  extreme  nervous 
susceptibility  continues  for  a  considerable  time  after  delivery,  and  indi- 
cates the  necessity  of  keeping  the  lying-in  patient  as  free  from  all  sources 
of  excitement  as  possible. 

Fall  of  the  Pulse. — Immediately  after  delivery  the  pulse  falls ;  and  p 
the  importance  of  this,  as  indicating  a  favorable  state  of  the  patient,  has 
already  been  alluded  to.  The  condition  of  the  pulse  has  been  carefully 
studied  l^y  Blot,'  who  has  shown  that  this  diminution,  whicli  he  believes 
to  be  (jonnected  with  a  diminislicd  tension  in  the  arteries  due  to  the  sud- 
den arrest  of  th(!  uterine  circuhitioii,  continues  in  a  large  proportion  of 
f^ses  for  a  considerable  number  of  days  after  delivery ;  and  as  a  matter 
of  clinical  im[)ort  as  long  as  it  docs  the  patient  may  be  considered  to  be 
in  a  favorable  state.  In  many  instances  the  slowness  of  the  pulse  is 
remarkable,  often  sinking  to  50,  or  even  40,  beats  per  minute.  Any 
incr(;ase  above  the  normal   rate,  especially  if  at  all  continuous,  slujuld 

'  Arrh.;/('ii.  de.  Mrd.,  ]8(i4. 


548 


THE  PUERPERAL  STATE. 


always  be  carefully  noted  and  looked  on  with  suspicion.  In  connection 
with  this  subject,  however,  it  must  be  remembered  that  in  puerperal 
women  the  most  trivial  circumstances  may  cause  a  sudden  rise  of  the 
pulse.  This  must  be  familiar  to  every  practical  obstetrician  who  has 
constant  opportunities  of  observing  this  effect  after  any  transient  excite- 
ment or  fatigue.  In  lying-in  hospitals  it  has  generally  been  observed 
that  the  occurrence  of  any  particularly  bad  case  will  send  up  the  pulse 
of  all  the  other  patients  who  may  have  heard  of  it. 

Temperature  in  the  Puerperal  State. — The  temperature  in  tlie  lying-in 
state  affords  much  valuable  information.  During  and  for  a  short  time 
after  labor  there  is  a  slight  elevation.  It  soon  falls  to,  or  even  some- 
^^^^diat  below,  the  normal  level.  Squire  found  that  the  fall  occurred 
within  twenty-four  hours,  sometimes  within  twelve  hours,  after  the  ter- 
mination of  labor.^  For  a  few  days  there  is  often  a  slight  increase  of 
temperature,  especially  toward  the  evening,  which  is  probably  caused  by 
the  rapid  oxidation  of  tissue  in  connection  with  the  involution  of  the 
uterus.  In  about^  forty^eight  hours  there  is  a  rise  connected  with  the 
establishment  of  lactation  amounting  to  one  or  two  degrees  over  normal 
level,  but  this  again  subsides  as  soon  as  the  milk  is  freely  secreted.  Crede 
has  also  shown  ^  that  rapid  but  transient  rises  of  temperature  may  occur 
at  any  period,  connected  with  trivial  causes,  such  as  constipation,  errors 
of  diet,  or  mental  disturbances.  But  if  there  be  any  rise  of  temperature 
which  is  at  all  continuous,  especially  to  over  100°  F.,  and  associated 
with  rapidity  of  the  pulse,  there  is  reason  to  fear  the  existence  of  some 
complication. 

^llieJiecretionsa/ncl^Ex^^  — The  various  secretions  and  excretions 

are  carried  on  with  increased  activity  after  labor.  The  skin  especially 
acts  freely,  the  patient  often  sweating  profusely.  There  is  also  an  abun- 
dant secretion  of  urine,  but  not  uncommonly  a  difficulty  of  voiding  it, 
either  on  account  of  temporary  paralysis  of  the  neck  of  the  bladder, 
resulting  from  the  pressure  to  which  it  has  been  subjected,  or  from  swell- 
ing and  occlusion  of  the  urethra.  For  the  same  reason  the  rectum  is 
sluggish  for  a  time,  and  constipation  is  not  infrequent.  The  appetite  is 
generally  indifferent,  and  the  patient  is  often  thirsty. 

Secrdixm^of  the  secretion 

of  milk  becomes  established,  and  this  is  occasionally  accompanied  by  a 
ceiiain  amount  of  constitutional  irritation.  The  breasts  often  become 
turgid,  hot,  and  painful.  There  may  or  may  not  be  some  general  dis- 
turbance, quickening  of  pulse,  elevation  of  temperature,  possibly  slight 
shivering,  and  a  general  sense  of  oppression,  which  are  quickly  relieved 
as  the  milk  is  formed  and  the  breasts  emptied  by  suckling.  Squire  says 
that  the  most  constant  phenomenon  connected  with  the  temperature  is  a 
slight  elevation  as  the  milk  is  secreted,  rapidly  falling  when  lactation  is 
established.  Barker  noted  elevation  either  of  temperature  or  pulse  in 
only  4  out  of  52  cases  M'hich  were  carefully  Matched.  There  can  be 
little  doubt  that  the  importance  of  the  so-called  "  milk  fever  "  has  been 
immensely  exaggerated,  and  its  existence  as  a  normal  accompaniment  of 
the  puerperal  state  is  more  than  doubtful.     It  is  certain,  however,  that 

^  "  Puerperal  Temperatures,"  Obstetrical  Transactions,  vol.  ix. 
"^Monat.  f.  Geburt,  Dec,  1868. 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.  549 

in  a  small  minority  of  cases  there  is  an  appreciable  amount  of  disturb- 
ance about  the  time  that  the  milk  is  formed.  Out  of  423  cases,  ]\Iacan  ^ 
found  that  in  114,  or  about  27  per  cent.,  there  was  no  rise  in  tempera- 
ture ;  in  226  the  temperature  did  rise  to  100°  and  over,  and  of  these  in 
32,  or  a  little  over  7  per  cent.,  the  only  ascertainable  cause  was  a  painful 
or  distended  condition  of  the  breast.  Many  modern  writers,  such  as 
Winckel,  Griinewaldt,  and  D'Espine,  entirely  deny  the  connection  of 
this  disturbance  with  lactation,  and  refer  it  to  a  slight  and  transient 
septicaemia.  Graily  Hewitt  remarks  that  it  is  most  commonly  met  with 
when  the  patient  is  kept  low  and  on  deficient  diet  after  delivery,  espe- 
cially when  the  system  is  below  par  from  hemorrhage  or  any  other  cause. 
This  observation  will  no  doubt  account  for  the  comparative  rarity  of 
febrile  disturbance  in  connection  with  lactation  in  these  days,  in  which 
the  starving  of  puerperal  patients  is  not  considered  necessary.  It  is  cer- 
tain that  anything  deserving  the  name  of  milk  fever  is  now  altogether 
exceptional,  and  such  feverishness  as  exists  is  generally  quite  transient. 
It  is  also  a  fact  that  it  is  most  apt  to  occur  in  delicate  and  weakly 
women,  especially  in  those  who  do  not  or  are  unable  to  nurse.  There 
does  not,  however,  seem  to  be  any  sufficient  reason  for  referring  it,  even 
when  tolerably  well  marked,  to  septicaemia.  The  relief  which  attends 
the  emptying  of  the  breasts  seems  sufficient  to  prove  its  connection  with 
lactation,  and  the  discomfort  which  is  necessarily  associated  with  the 
swollen  and  turgid  mammae  is  of  itself  quite  sufficient  to  explain  it. 

Sugar  in  the   Urine. — In  the  urine  of  women  during  lactation  an  ^Jv^^Ji^^  * 
appreciable  amount  of  sugar  may  readily  be  detected.     The  amount 'l/^AX-M.  ^ 
varies  according  to  the  condition  of  the  breasts.     It  increases  when  (>-cOvXl* 
they  are  turgid  and  congested,  and  is  therefore  most  abundant  in  women 
in  whom  the  breasts  are  not  emptied,  as  when  the  child  is  dead  or  when 
lactation  is  not  attempted. 

Contixtdion  of  the  Uterus  after  Delivery. — Immediately  after  delivery  I 
the  uterus  contracts  firmly,  and  can  be  felt  at  the  lower  part  of  the  abdo- 
men  as  a  hard,  firm  mass  about  the  size  of  a  cricket-ball.  After  a  timej 
it  again  relaxes  somewhat,  and  alternate  relaxations  and  contractions  go 
on  at  intervals  for  a  considerable  time  after  the  expulsion  of  the  placenta. 
The  more  complete  and  permanent  the  contraction,  the  greater  the  safety 
and  comfort  of  the  patient ;  for  when  the  organ  remains  in  a  state  of 
partial  relaxation  coagula  are  apt  to  be  retained  in  its  cavity,  while  for 
the  same  reason  air  enters  more  readily  into  it.  Hence  decomposition  is 
fav^ored  and  the  chances  of  septic  absorption  are  much  increased,  while 
even  when  this  does  not  occur  the  muscular  fibres  are  excited  to  contract 
and  severe  after-pains  are  produced. 

Subsequent  Diminution  in  the  Size  of  the  Uterus. — After  the  first  few 
days  the  diminution  in  the  size  of  the  uterus  progresses  Avith  great  rapid- 
ity. By  about  the  sixth  day  it  is  so  much  lessened  as  to  project  not 
more  than  \\  or  2  inches  above  the  pelvic  brim,  while  by  the  eleventh 
day  it  is  no  longer  to  l)e  made  out  by  abdonu'nal  palpation.  Its  in- 
creased size  is,  ho\v(;v('r,  still  nppanjut  ]i('r  vaginani,an(l  should  occasion 
arise  for  making  internal  cxainination,  tin;  mass  of  the  lower  segment 
of  the  uterus,  with   its  llahhy  and  j)atidous  cervix,  can  be  felt  for  some 

'  JMIjUu  Journ.  o/  Mcff.  Science,  May,  1878. 


550  THE  PUERPERAL  STATE. 

weeks  after  delivery.  This  may  sometimes  be  of  practical  value  in  cases 
in  Avliich  it  is  necessary  to  ascertain  the  fact  of  recent  delivery,  and 
under  these  circumstances,  as  pointed  out  by  Simpson,  the  uterine  sound 
would  also  enable  us  to  prove  that  the  cavity  of  the  uterus  is  consider- 
ably elongated.  Indeed,  the  normal  condition  of  the  uterus  and  cervix 
is  not  regained  untH  six  weeks^or  two  months  after  labor.  These  obser- 
vations are  corroborated  by  investigations  on  the  weight  of  the  organ  at 
different  periods  after  labor.  Thus,  Heschl^  has  shown  that  the  uterus 
immediately  after  delivery  w^eighs  about  22  to  24  oz.,  within  a  w^eek  it 
weighs  19  to  21  oz.,  and  at  the  end  of  the  second  week  10  to  11  oz.  only. 
At  the  end  of  the  third  week  it  weighs  5  to  7  oz.,  but  it  is  not  until  the 
end  of  the  second  month  that  it  reaches  its  normal  weight.  Hence  it 
appears  that  the  most  rapid  diminution  occurs  during  the  second  week 
after  delivery. 

Fatty  Transformation  of  the  Muscular  Fibres. — The  mode  in  wdiich 
this  diminution  in  size  is  effected  is  by  the  transformation  of  the  muscu- 
lar fibres  into  molecular  fat,  which  is  absorbed  into  the  maternal  vascular 
system,  which  therefore  becomes  loaded  with  a  large  amount  of  effete 
material.  Hesclil  has  shown  that  the  entire  mass  of  the  enlarged  uterine 
muscles  are  removed,  and  replaced  by  newly-formed  fibres,  which  com- 
mence to  be  developed  about  the  fourth  week  after  delivery,  the  change 
being  complete  about  the  end  of  the  second  month.  Generally  speaking, 
involution  goes  on  without  interruption.  It  is,  however,  apt  to  be  inter- 
fered with  by  a  variety  of  causes,  such  as  premature  exertion,  intercur- 
rent disease,  and,  very  probably,  by  neglect  of  lactation.  Hence  the 
uterus  often  remains  large  and  bulky,  and  the  foundation  for  many  sub- 
sequent uterine  ailments  is  laid. 

Changes  in  the  Uterine  Vessels. — Williams  has  drawn  attention  to 
changes  occurring  in  the  vessels  of  the  uterus,  some  of  which  seem  to  be 
permanent,  and  may,  should  further  observations  corroborate  his  inves- 
tigations, prove  of  value  in  enabling  us  to  ascertain  wdi ether  a  uterus  is 
nulliparous  or  the  reverse — a  question  which  may  be  of  medico-legal 
importance.  After  pregnancy  he  found  all  the  vessels  enlarged  in  calibre. 
The  coats  of  the  arteries  are  thickened  and  hypertrophied,  and  this  he 
has  observed  even  in  the  uteri  of  aged  women  who  have  not  borne  chil- 
dren for  many  years.  The  venous  sinuses,  especially  at  the  placental 
site,  have  their  walls  greatly  thickened  and  convoluted,  and  contain  in 
their  centre  a  small  clot  of  blood  (Fig.  192).  This  thickening  attains 
its  greatest  dimensions  in  the  third  month  after  gestation,  but  traces  of  it 
may  be  detected  as  late  as  ten  or  twelve  wrecks  after  labor. 

Changes  in  the  Uterine  Mucous  Membrane. — The  changes  going  on  in 
the  lining  membrane  of  the  uterus  immediately  after  delivery  are  of 
great  importance  in  leading  to  a  knowledge  of  the  puerperal  state,  and 
have  already  been  discussed  when  describing  the  decidua  (p.  104).  Its 
cavity  is  covered  with  a  reddish-gray  film  formed  of  blood  and  fibrin. 
The  open  mouths  of  the  uterine  sinuses  are  still  visible,  more  especially 
over  the  site  of  the  placenta,  and  thrombi  may  be  seen  projecting  from 
them.  The  ])lacental  site  can  be  distinctly  made  out  in  the  form  of  an 
irregularly  oval  patch,  where  the  lining  membrane  is  thicker  than  elsewhere. 

^  Researches  on  the  Conduct  of  the  Humun  Uterus  after  Delivery. 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT. 


551 


Contraction  of  the  Vagina,  etc. — The  vagina  soon  contracts,  and  by 
the  time  the  puerperal  month  is  over  it  has  returned  to  its  normal 
dimensions,  but  after  childbearing  it  always  remains  more  lax  and  less 
rugose  than  in  nulliparae.  The  vulva,  at  first  very  lax. and  much  dis- 
tended, soon  regains  its  former  state.     The  abdominal  parietes  remain 

Fig.  192. 


Section  of  a  Uterine  Sinus  from  a  Placental  Site  Nine  AVeeks  after  Delivery.    (After  Williams.) 

loose  and  flabby  for  a  considerable  time,  and  the  white  streaks  produced 
by  the  distension  of  the  cutis  very  generally  become  permanent.  In  some 
women,  especially  when  proj)er  support  by  bandaging  has  not  been  given, 
the  abdomen  remains  permanently  loose  and  pendulous. 

The  Lochial  Discharge. — From  the  time  of  delivery  up  to  about 
three  weeks  afterward  a  discharge  escapes  from  the  interior  of  the  ute- 
rus known  as  the  lochia.  Atjfirst^this  consists  almost  entirely  of  _pure 
blood,  mixed  with  a  variable  amount  of  coagula.  If  efficient  uterine 
contraction  has  not  been  secured  after  the  expulsion  of  the  placenta, 
coagula  of  considerable  size  are  frequently  expelled  with  the  lochia  for 
one  or  two  days  after  delivery.  In  tln;ee_j)r_fbur_days  the  distinctly 
bloody  character  of  the  lochia  is  altered.  They  have  a  reddish  watery 
appearance,  and  are  known  as  the  locJda  rubra  or  cruenta.  According 
to  tli(.'  researches  of  Wcrthcinicr,^  they  are  at  this  time  composed  chiefly 
of  l)loo(l-cor|)Uscles,  mixed  with  e])ith('liuin  scales,  mucous  corpuscles, 
and  tii(3  debris  of  the  decidua.  TJie  change  in  tlie  appearance  of  tlie 
dis(;harge  progresses  gradually,  and  about  the  se vejith  j^r  eightli_day  it 
has  no  longer  a  red  color,  but  is  a  pale-greenish  fluid  with  a  peculiar 
sickening  and  di.sagrceable  odor,  and  is  familiarly  described  as  the  "green 

'   VirrJif,w\  Arch.,  18()1. 


552  THE  PUERPEBAL  STATE. 

waters."  It  now  contains  a  small  quantity  of  blood-corpuscles,  which 
lessen  in  amount  from  day  to  day,  but  a  considerable  number  of  pus- 
corpuscles,  ^vhich  remain  the  principal  constituent  of  the  discharge  until 
it  ceases.  Besides  these,  epithelial  scales,  fatty  granules,  and  crystals  of 
cholesterin  are  observed.  Occasionally  a  small  infusorium,  which  has 
been  named  the  "  Trichomena  vaginalis,"  has  been  detected,  but  it  is  not 
of  constant  occurrence. 

Variation  in  its  Amount  and  Duration. — The  amount  of  the  lochia 
varjesjnuch,  and  in  some  women  it  is  habitually  more  abundant  than  in 
j)thers.  Under  ordinary  circumstances  it  is  very  scanty  after  the  first 
fortnight,  but  occasionally  it  continues  somewhat  abundant  for  a  month 
or  more  without  any  bad  results.  It  is  apt  again  to  become  of  a  red 
color  and  to  increase  in  quantity  in  consequence  of  any  slight  excitement 
or  disturbance.  If  this  red  discharge  continues  for  any  undue  length 
of  time,  there  is  reason  to  suspect  some  abnormality,  and  it  may  not 
unfrequently  be  traced  to  slight  lacerations  about  the  cervix  which  have 
not  healed  properly.  This  result  may  also  follow  premature  exertion, 
interfering  with  the  proper  involution  of  the  uterus ;  and  the  patient 
should  certainly  not  be  allowed  to  move  about^sjjjng  as  much  colored 
discliarge  is  going  on. 

Occasional  Fetor  of  the  Discharge. — Occasionally  the  lochia  have  an 
intensely  fetid  odor.     This  must  always  give  rise  to  some  anxiety,  since 
it  often  indicates  the  retention  and  putrefaction  of  coagula  and  involves 
the  risk  of  septic  absorption.     It  is  not  very  rare,  however,  to  observe  a 
most  disagreeable  odor  persist  in  the  lochia  without  any  bad  results. 
The  fetor  always  deserves  careful  attention,  and  an  endeavor  should  be 
made  to  obviate  it  by  directing  the  nurse  to  syringe  out  the  vagina  freely 
night  and  morning  with  Condy's  fluid  and  water,  while,  if  it  be  associ- 
ated with  quickened  pulse  and  elevated  temperature,  other  measures,  to 
be  subsequently  described,  will  be  necessary. 
^The  Afteij^Pain^s.- — The  after-pains,  which  many  childbearing  women 
I  dread  even  more  than  the  labor-pains,  are  irregular  contractions  occur- 
ring for  a  varying  time  after  delivery,  and  resulting  from  the  eiforts  of 
[jhe  uterus  to  expel  coagula  which  have  formed  in  its  interior.    If,  there- 
fore, special  care  be  taken  to  secure  complete  and  permanent  contraction 
after  labor,  they  rarely  occur,  or  to  a  very  slight  extent.     Their  depend- 
ence on  uterine  inertia  is  evidenced  by  the  common  observation  that  they 
are  seldom  met  with  in  primiparre,  in  whom  uterine  contraction  may  be 
supposed  to  be  more  efficient,  and  are  more  frequent  in  women  who  have 
I  borne  many  children.     They  are  a  preventable  complication,  and  one 
I  which  need  not  give  rise  to  any  anxiety :   they  are,  indeed,  rather  salu- 
Ltary  than  the  reverse,  for  if  coagula  be  retained  in  utero,  the  sooner  they 
I  are^  expelled  the  better.     The  after-pains  generally  begin  a  few  hours 
I  after  delivery,  and   continue  in    bad  cases  for  three  or  four  days,  but 
L  seldom  longer.     They  are  generally  increased  when  the  mammte  are  irri- 
tated by  suction.     When  at  their  height  they  are  often  relieved  by  the 
expulsion  of  the  coagula.      In  some  severe  cases  they  are  apparently 
neuralgic  in  character,  and  do  not  seem  to  depend  on  the  retention  of 
coagula.      They  may  be  readily  distinguished  from  pains  due  to  more 
serious  causes  by  feeling  the  enlarged  uterus  harden  under  their  influ- 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.  553 

ence,  by  the  uterus  not  being  tender  on  pressure,  and  by  the  absence  of 
any  constitational  symptoms. 

Management  of  Women  after  Delivery. — The  management  of  women 
after  childbirth  has  varied  much  at  different  times  according;  to  fashion 
or  theory.  The  dread  of  inflammation  long  influenced  the  professional 
mind,  and  caused  the  adoption  of  a  strictly  antiphlogistic  diet,  which  led 
to  a  tardy  convalescence.  The  recognition  of  the  essentially  physiologi- 
cal character  of  labor  has  resulted  in  more  sound  views,  with  manifest 
advantage  to  our  patients.  The  main  facts  to  bear  in  mind  with  regard 
to  the  puerperal  woman  are — her  nervous  susceptibility,  which  necessi- 
tates qujet  and  absence  of  all  excitemeiit ;  the  importance  of  favoring 
involution  by  prolongedj^ ;  and  the  risk  of  septicaemia,  which  calls  for 
perfect  cleanliness  and  attention  to  hygienic  precautions.  _ 

The  Admmistration  of  Opiates  is  generally  Unadvlsable. — As  soon  as 
we  are  satisfied  that  the  uterus  is  perfectly  contracted  and  that  all  risk 
of  hemorrhage  is  over,  the  patient  should  be  left  to  sleep.  Many  prac- 
titioners administer  an  opiate,  but,  as  a  matter  of  routine,  this  is  cer- 
tainly not  good  practice,  since  it  checks  the  contractions  of  the  uterus 
and  often  produces  unpleasant  effects.  Still,  if  the  labor  have  been  long 
and  tedious  and  the  patient  be  much  exhausted,  1 5  or  20  drops  of  Bat- 
tley's  solution  may  be  administered  with  advantage. 

Attention  to  the  State  of  the  Pulse,  Bladder,  and  Uterus. — Within  a 
few  hours  the  patient  should  be  seen,  and  at  the  first  visit  particular 
attention  should  be  paid  to  the  state  of  the  pulse,  the  uterus,  and  the 
bladder.  The  pulse  duriug  the  whole  period  of  convalescence  should^ 
be  carefully  watched,  and  if  it  be  at  all  elevated  the  temperature  should 
at  once  be  taken.  If  the  pulse  and  temperature  remain  normal,  we  may 
be  satisfied  that  things  are  going  on  well ;  but  if  the  one  be  quickened 
and  the  other  elevated,  some  disturbance  or  complication  may  be  appre- 
hended. The  abdomen  should  be  felt  to  see  that  the  uterus  is  not 
unduly  distended  and  that  there  is  no  tenderness.  After  the  first  day 
or  two  this  is  no  longer  necessary. 

Treatment  of  Retention  of  Urine. — Sometimes  the  patient  cannot  at 
first  void  the  urine,  and  the  application  of  ajiot^ponge  over  the  pubes 
may  enable  her  to  do  so.  If  the  retention  of  urine  be  due  to  temporary 
paralysis  of  the  bladder,  three  or  four  20-minim  doses  of  the  liquid 
extract  of  ergot,  at  intervals  of  half  an  hour,  may  prove  successful. 
Many  hours  should  not  be  allowed  to  elapse  without  relieving  the 
patient  by  the  catheter,  since  prolonged  retention  is  only  likely  to  make 
matters  worse.  Subsequently,  it  may  be  necessary  to  empty  the  bladder 
night  and  morning  until  the  patient  regain  her  ])ower  over  it  or  until 
the  swelling  of  the  urethra  subsides,  and  this  will  generally  be  the  case 
in  a  few  days.  Occasionally  the  bladder  becomes  largely  distended,  and 
is  relieved  to  some  degree  by  dribbling  of  urine  from  the  urethra.  Such 
a  state  of  things  may  deceive  the  patient  and  nurse,  and  may  produce 
serious  consecjuences  by  causing  cystitis.  Attention  to  the  condition 
of  the  abdomen  will  prevent  the  ])ractition(!r  from  being  deceived, 
for  in  addition  to  some  constitutional  distui-bancc;  a  large,  tender, 
and  finctiiating  swelling  will  be  found  in  the  hypogastric  region,  dis- 
tinct from  the  uterus,  which  it  displaces  to  one  or  other  side.     The 


554  THE  PUERPERAL  STATE. 

catheter  will  at  once  prove  that  this  is  produced  by  distciisi(Hi  of  the 
bladder. 

Treatment  of  Severe  After-Paim. — If  the  after-pains  be  very  severe 
an  opiate  may  be  administered,  or  if  the  lochia  be  not  over-abundant  a 
linseed-meal  poultice  sprinkled  with  laudanum  or  with  the  chloroform 
and  belladonna  liniment  may  be  applied.  If  proper  care  have  been 
taken  to  induce  uterine  contraction,  they  will  seldom  be  sufficiently 
severe  to  require  treatment.  In  America  quinine,  in  doses  of  10  grains 
t\\ice  daily,  has  been  strongly  recommended,  especially  when  opiates  fail 
and  ^vhen  the  pains  are  neuralgic  in  character ;  and  I  have  found  this 
remedy  answer  extremely  well.  The  quinine  is  best  given  in  solution 
wdth  10  or  15  minims  of  hydro bromic  acid,  which  materially  lessens  the 
unpleasant  head  symptoms  often  accompanying  the  administration  of 
such  large  doses. 

Diet  and  Regimen. — The  diet  of  the  puerperal  patient  claims  careful 
attention,  the  more  so  as  old  prejudices  in  this  respect  are  as  yet  far  frijm 
exploded,  and  as  it  is  by  no  means  rare  to  find  mothers  and  nurses  who 
still  cling  tenaciously  to  the  idea  that  it  is  essential  to  prescribe  a  low 
regimen  for  many  days  after  labor.  The  erroneousness  of  this  plan  is 
now  so  thoroughly  recognized  that  it  is  hardly  necessary  to  argue  the 
point.  There  is,  however,  a  tendency  in  some  to  err  in  the  opposite 
direction,  which  leads  them  to  insist  on  the  patient's  consuming  solid 
food  too  soon  after  delivery,  before  she  has  regained  her  appetite,  thereby 
producing  nausea  and  intestinal  derangement.  Our  best  guide  in  this 
matter  is  the  feelings  of  the  patient  herself.  If,  as  is  often  the  case,  she 
be  disinclined  to  eat,  there  is  no  reason  Avhy  she  should  be  urged  to  do 
so.  A  good  cup  of  beef-tea,  some  bread  and  milk,  or  an  egg  beat  up 
with  milk  may  generally  be  given  with  advantage  shortly  after  delivery, 
and  many  patients  are  not  inclined  to  take  more  for  the  first  day  or  so. 
If  the  patient  be  hungry,  there  is  no  reason  why  she  should  not  have 
some  more  solid  but  easily-digested  food,  such  as  white  fish,  chicken,  or 
sweetbread ;  and  after  a  day  or  two  she  may  resume  her  ordinary  diet, 
bearing  in  mind  that,  being  confined  to  bed,  she  cannot  with  advantage 
consume  the  same  amount  of  solid  food  as  when  she  is  up  and  about. 
Dr.  Oldham,  in  his  presidential  address  to  the  Obstetrical  Society,^  has 
some  apposite  remarks  on  this  point  which  are  worthy  of  quotation : 
"  A  puerperal  month  under  the  guidance  of  a  monthly  nurse  is  easily 
drawn  out,  and  it  is  well  if  a  love  of  the  comforts  of  illness  and  the  per- 
suasion of  being  delicate,  which  are  the  infirmities  of  many  women,  do 
not  induce  a  feeble  life  Mdiich  long  survives  after  the  occasion  of  it  is 
forgotten.  I  know  no  reason  why,  if  a  woman  is  confined  early  in  the 
morning,  she  should  not  have  her  breakfast  of  tea  and  toast  at  nine,  her 
luncheon  from  some  digestible  meat  at  one,  her  cup  of  tea  at  five,  her 
dinner  with  chicken  at  seven,  and  her  tea  again  at  nine,  or  the  equiva- 
lent, according  to  the  variation  of  her  habits  of  living.  Of  course,  there 
is  the  common-sense  selection  of  articles  of  food,  guarding  against  excess 
and  avoiding  stimulants.  But  gruel  and  slops  and  all  intermediate 
feeding  are  to  be  avoided."  No  one  who  has  seen  both  methods  adopted 
can  fail  to  have  been  struck  with  the  more  rapid  and  satisfactory  conva- 

'  Obsiet.  7Va»s..  vol.  vi. 


THE  PUERPERAL  STATE  AND  ITS  MANAGEMENT.  555 

lescence  which  takes  place  wlien  the  patient's  strength  is  not  weakened 
by  an  unnecessarily  low  diet.  Stimulants,  as  a  rule,  are  not  required, 
but  if  the  patient  be  weakly  and  exhausted,  or  if  she  be  accustomed  to 
their  use,  there  can  be  no  reasonable  objection  to  their  judicious  admin- 
istration. [As  a  rule,  in  the  United  States  puerperal  women  have  not 
been  accustomed  to  the  use  of  stimulants,  and  such  are  not  advisable 
during  their  convalescence.  The  old  system  of  starvation  for  three  days 
has  been  done  away  with,  but  the  opposite  is  also  to  be  avoided.  I 
believe  in  a  spare  diet  for  the  robust  and  in  feeding  up  the  delicate. 
Where  much  blood  has  been  lost  I  have  found  great  benefit  from  the  use 
of  essence  of  beef,  given  in  severe  cases  quite  largely.  As  a  rule,  that 
made  from  three  pounds  of  beef  is  to  be  given  daily  for  two  weeks,  but 
I  have  used  in  a  very  extreme  case  as  high  as  eleven  pounds.  The 
removal  of  the  ansemic  pallor  is  sometimes  very  decided  within  fifteen 
days  under  this  diet.  Of  course  the  patient  is  to  have  a  regular  diet  in 
addition  to  the  essence  of  beef. — Ed.] 

Attention  to  Oleanliness,  etc. — Immediately  after  delivery  a  warm 
napkin  is  applied  to  the  vulva,  and  after  the  patient  has  rested  a  little 
the  nurse  removes  the  soiled  linen  from  the  bed  and  washes  the  external 
genitals.  It  is  impossible  to  pay  too  much  attention  during  the  siibse-  J 
quent  progress  of  the  case  to  the  maintenance  of  perfect  cleanliness. 
Perfectly  antiseptic  midwifery  is  no  doubt  an  impossibility,  but  a  near 
approach  to  it  may  be  made,  and  the  greater  the  care  taken  the  more 
certainly  will  the  safety  of  the  patient  be  ensured.^  It  will  be  a  wise 
precaution  to  advise  the  nurse  never  to  touch  the  genitals  for  the  first 
few  days  unless  her  hands  have  been  moistened  in  a  l-in-20  solution  of 
carbolic  acid  or  a  1-in-lOOO  solution  of  perchloride  of  mercury,  or  lubri- 
cated with  carbolized  oil.     The  linen  should  be  frequently  changed,  and 

'  The  following  rules  I  have  for  the  past  year  or  two  distribnted  to  the  monthly 
nurses  attending  my  own  patients,  with  tlie  result,  I  believe,  of  a  marked  improvement 
in  their  comfort  and  a  more  generally  satisfactory  convalescence  : 

Antiseptic  Kules  for  Monthly  Nurses. 

1.  Two  bottles  are  supplied  to  each  patient.  One  contains  a  mixture  of  phenol  or 
pure  carbolic  acid,  of  the  strength  of  one  part  to  twenty  of  water  (called  the  l-in-20 
solution),  the  other  carbolized  oil  (l-in-8). 

2.  A  small  basin  containing  the  l-in-20  solution  must  always  stand  by  the  bedside 
of  the  patient,  and  the  nurse  must  thorniu/hly  rinse  her  hands  in  it  every  time  she 
touches  the  patient  in  the  neighborhood  of  the  genital  organs,  for  washing  or  any  other 
purpose  whatsoevei',  before  or  during  labor  and  for  a  week  after  delivery. 

3.  All  sponges,  vaginal  and  rectal  pipes,  catheters,  etc.  must  be  dipped  in  the  l-in-20 
solution  before  being  used.  The  surfaces  of  slippers,  bedpans,  etc.  should  also  be 
sponged  witii  it. 

4.  Vaginal  pipes,  enema-tubes,  catheters,  etc.  should  be  smeared  with  tlie  carbolized 
oil  before  use. 

5.  Unless  express  directions  are  given  to  the  contrary,  the  vagina  should  be  syringed 
twice  daily  after  delivery  with  tiic  l-in-20  solution,  with  an  etfual  <|uantity  of  iiot  water 
added  to  it.  Occasionally  the  patient  finds  that  this  smarts  a  little,  in  which  case  the 
quantity  of  warm  water  may  be  slightly  increased. 

6.  Ail  water  used  for  washing  should  have  suilicient  Condy's  lliiid  dropped  into  it  to 
give  it  a  pale  pink  color. 

7.  All  soiled  linen,  diaper.s,  etc.  sliouid  lie  immediately  removed  frnm  tlie  bedroom. 
N.  B. — These  rules  are  for  the  purpose  of  protecting  the  patient  from  tlie  risk  arising 

from  accidental  coiitaiuiiiation  of  the  liaiids,  sjionges,  etc.  It  is  therefore  hoped  that 
they  will  be  faithfully  and  minutely  adhered  to. 


556  THE  PUERPERAL  STATE. 

all  dirty  linen  and  discharges  immediately  removed  from  the  apartment. 
The  vulva  should  be  washed  daily  with  Condy's  fluid  and  water,  and 
the  patient  will  derive  great  comfort  from  having  the  vagina  syringed 
gentlv  out  once  a  day  with  the  same  solution.  The  remarkable  diminu- 
tion of  mortality  which  has  followed  such  antiseptic  precautions  in  cer- 
tain lying-in  hospitals  in  Germany  well  shows  the  importance  of  these 
measures.  The  room  should  be  kept  tolerably  cool  and  fresh  air  freely 
admitted. 

\  Action  of  the  Boiceh. — It  is  customary  on  the  morning  of  the  second 
or  third  dav  to  secure  an  action  of  the  bowels ;  and  there  is  no  better 
w^ay  of  doing  this  than  by  a  large  enema  of  soap  and  water.  If  the 
patient  object  to  this  and  the  bowels  have  not  acted,  some  mild  aperient 
may  be  administered,  such  as  a  small  dose  of  castor  oil,  a  few  grains  of 
colocynth  and  henbane  pill,  or  the  popular  French  aperient  the  "  Tamar 
Indien." 

Lactation. — The  management  of  suckling  and  of  the  breasts  forms  an 
important  part  of  the  duties  of  the  monthly  nurse  which  the  practitioner 
should  himself  superintend.  This  will  be  more  conveniently  discussed 
under  the  head  of  Lactation. 
\  Importance  of  Prolonged  Rest. — The  most  important  part  of  the  man- 
agement of  the  puerperal  state  is  the  securing  to  the  patient  prolonged 
rest  in  the  horizontal  position,  in  order  to  fiivor  proper  involution  of  the 
^  uterus.  For  the  first  few  days  she  should  be  kept  as  quiet  and  still  as 
possible,  not  receiving  the  visits  of  any  but  her  nearest  relatives,  thus 
avoiding  all  chance  of  undue  excitement.  It  is  customary  among  the 
better  classes  for  the  patient  to  remain  in  bed  for  eight  or  ten  days ;  but, 
provided  she  be  doing  well,  there  can  be  no  objection  to  her  lying  on  the 
outside  of  the  bed  or  slipping  on  to  a  sofa  somewhat  sooner.  After  ten 
days  or  a  fortnight  she  may  be  permitted  to  sit  on  a  chair  for  a  little ; 

I  but  I  am  convinced  that  the  longer  she  can  be  persuaded  to  retain  the 
recumbent  position,  the  more  complete  and  satisfactory  will  be  the  prog- 

l^ress  of  involution ;  and  she  should  not  be  allowed  to  walk  about  until 
the  third  week,  about  which  time  she  may  also  be  permitted  to  take  a 
drive.  If  it  be  borne  in  mind  that  it  takes  from  six  weeks  to  two 
months  for  the  uterus  to  regain  its  natural  size,  the  reason  for  prolonged 
rest  will  be  obvious.  The  judicious  practitioner,  however,  while  insist- 
ing on  this  point,  will  take  measures  at  the  same  time  not  to  allow  the 
patient  to  lapse  into  the  habits  of  an  invalid  or  to  give  the  necessary 
rest  the  semblance  of  disease. 

Subsequent  Treatment. — Toward  the  termination  of  the  puerperal 
month  some  slight  tonic,  such  as  small  doses  of  quinine  with  phos- 
phoric acid,  may  be  often  given  with  advantage,  especially  if  convales- 
cence be  tardy.  Nothing  is  so  beneficial  in  restoring  the  patient  to  her 
usual  health  as  change  of  air,  and  in  the  upper  classes  a  short  visit  to 
the  seaside  may  generally  be  recommended,  with  the  certainty  of  much 
benefit. 


MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC.  557 


CHAPTER   II. 

MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC. 

Commencement  of  Respiration. — Almost  immediately  after  its  expul- 
sion a  healthy  child  cries  aloud,  thereby  showing  that  respiration  is 
established  ;  and  this  may  be  taken  as  a  signal  of  its  safety.  The  first 
respiratory  movements  are  excited  partially  by  reflex  action  resulting 
from  the  contact  of  the  cold  external  air  with  the  cutaneous  nerves,  and 
partly  by  the  direct  irritation  of  the  medulla  oblongata  in  consequence 
of  the  circulation  through  it  of  blood  no  longer  oxygenated  in  the 
placenta. 

Apparent  Death  of  the  New-horn  Child. — Not  infrequently  the  child 
is  born  in  an  apparently  lifeless  state.  This  is  especially  likely  to  be 
the  case  when  the  second  stage  of  labor  has  been  unduly  prolonged,  so 
that  the  head  has  been  subjected  to  long-continued  pressure.  The  utero- 
placental circulation  is  also  apt  to  be  injuriously  interfered  with  before 
the  birth  of  the  child  when  a  tardy  labor  has  produced  tonic  contraction 
of  the  uterus  and  consequent  closure  of  the  uterine  sinuses,  or,  more 
rarely,  from  such  causes  as  the  injudicious  administration  of  ergot,  pre- 
mature separation  of  the  placenta,  or  compression  of  the  umbilical  cord. 
In  any  of  these  cases  it  is  probable  that  the  arrest  of  the  utero-placental 
circulation  induces  attempts  at  inspiration  which  are  necessarily  fruit- 
less, since  air  cannot  reach  the  lungs,  and  the  foetus  may  die  asphyx- 
iated ;  the  existence  of  the  respiratory  movement  being  proved  on  post- 
mortem examination  by  the  presence  in  the  lungs  of  liquor  amnii,  mucus, 
and  meconium,  and  by  the  extravasation  of  blood  from  the  rupture  of 
their  engorged  vessels. 

Appearance  of  the  Child  in  such  Cases. — In  most  cases,  when  the 
child  is  born  in  a  state  of  apparent  asphyxia,  its  face  is  swollen  and  of 
a  dark  livid  color.  It  not  infrequently  makes  one  or  two  feeble  and 
gasping  efforts  at  respiration,  without  any  definite  cry ;  on  auscultation 
the  heart  may  be  heard  to  beat  weakly  and  slowly.  Under  such  circum- 
stances there  is  a  fair  hope  of  its  recovery.  In  other  cases  the  child,  instead 
of  being  turgid  and  livid  in  the  face,  is  pale,  with  flaccid  limbs,  and  no 
appreciable  cardiac  action ;  then  the  prognosis  is  much  more  unfavorable. 

Treatment  of  Apparent  Death. — No  time  should  be  lost  in  endeavor- 
ing to  excite  res])iration  ;  and  at  first  this  must  be  done  by  applying 
suitable  stimulants  to  the  cutaneous  nerves  in  the  hope  of  exciting  reflex 
action.  The  cord  should  be  at  once  tied  and  the  child  removed  from 
the  mother,  for  the  final  uterine  contra(!tions  have  so  completely  arrested 
the  utero-placental  circulation  as  to  render  it  no  longef  of  any  value. 
If  the  fiice  be  v(;ry  livid,  a  few  dro])s  of  blood  may  with  advantage  be 
allowed  to  flow  from  tin;  cord  before  it  is  tied,  with  th(!  view  of  relieving 
the  embarrassed  circulation.  Very  often  some  slight  stimulus,  sucli  as  w<a>o-' 
one  or  two  sharp  sla])S  on  the  thorax  or  ra])idly  rubbing  the  body  with     ^ 


sy^ 


558  THE  PUERPERAL  STATE. 

brandy  poured  into  the  palms  of  the  hands,  wjll  suffice  to  induce  respira- 
tion. Failing  this,  nothing  acts  so  well  as  the  sudden  and  instantaneous 
application  ot*  heat  and  cold.  For  this  purpose  extremely  hot  water  is 
placed  in  one  basin,  and  cjuite  cold  water  in  another.  Taking  the  child 
by  the  shoulders  and  legs,  it  should  be  dipped  tor  a  single  moment  into 
the  hot  water  and  then  into  the  cold ;  and  these  alternate  applications 
may  be  repeated  once  or  twice  as  occasion  requires.  The  eiiect  of  this 
measure  is  often  very  marked,  and  I  have  frequently  seen  it  succeed 
when  prolonged  efforts  at  artificial  respiration  had  been  made  in  vain. 

Artificial  Jicsjnrgtion. — If  these  means  fail  an  endeavor  nmst  be  at 
once  made  to  carry  on  respiration  artificially.  The  Sylvester  method  is, 
on  the  whole,  that  which  is  most  easily  applied,  and,  on  account  of  the 
compressibility  of  the  thorax,  it  is  peculiarly  suitable  for  infants.  The 
child  being  laid  on  its  back  with  the  shoulders  slightly  elevated,  the 
elboAvs  are  grasped  by  the  operator  and  alternately  raised  above  the  head 
and  slowly  depressed  against  the  sides  of  the  thorax,  so  as  to  produce  the 
effect  of  inspiration  and  expiration.  If  this  do  not  succeed,  the  Marshall 
Hall  method  may  be  substituted,  and  one  or  more  of  the  plans  of  excit- 
ing reflex  action  through  the  cutaneous  nerves  may  be  alternated  with  it. 
—~Insu^gMgn^oj[Jhe  Lokugs. — Other  means  of  exciting  respiration  have 
been  recommended.  One  of  them,  much  used  abroad,  is  the  artificial 
insufflation  of  the  lungs  by  means  of  a  flexible  catheter  guided  into 
the  glottis.  It  is  not  difficult  to  pass  the  end  of  a  catheter  into  the 
glottis,  using  the  little  finger  as  a  guide ;  and,  once  in  position,  it  may 
be  used  to  blow  air  gently  into  the  lungs,  which  is  expelled  by  compres- 
sion on  the  thorax,  the  insufflation  being  repeated  at  short  intervals  of 
about  ten  seconds.  One  advantage  of  this  plan  is  that  it  allows  the 
liquor  amnii  and  other  fluids,  which  may  have  been  drawn  into  the 
lungs  in  the  premature  efforts  at  respiration  before  birth,  to  be  sucked 
up  into  the  catheter,  and  so  removed  from  the  lungs.  The  same  effect 
may  be  produced,  but  less  perfectly,  by  placing  the  hand  over  the  nos- 
trils of  the  child,  blowing  into  its  mouth,  and  immediately  afterward 
compressing  the  thorax.  [^]  One  of  these  two  methods  should  certainly 
be  tried  if  all  other  means  have  failed.  Faradization  along  the  course 
of  the  phrenic  nerves  is  a  promising  means  of  inducing  respiration  which 
should  be  used  if  the  proper  apparatus  can  be  procured.  Encouragement 
to  persevere  in  our  endeavors  to  resuscitate  the  child  may  be  derived 
from  the  numerous  authenticated  instances  of  success  after  the  lapse  of 
a  considerable  time,  even  of  an  hour  or  more.  As  long  as  the  cardiac 
pulsations  continue,  however  feebly,  there  is  no  reason  to  despair.  ^ 

Wmhing  and  Dressing  of  the  Child. — When  the  child  cries  lustily 
from  the  first,  it  is  customary  for  the  nurse  to  wash  and  dress  it  as  soon 
as  her  immediate  attendance  on  the  mother  is  no  longer  required.  For 
this  purpose  it  is  placed  in  a  bath  of  warm  water  and  carefully  soaped 
and  sponged  from  head  to  foot.  With  the  view  of  flicilitating  the 
removal  of  th(?  unctuous  material  with  which  it  is  covered,  it  is  usual 
to  anoint  it  with  cold  cream  or  olive  oil,  which  is  washed  off  in  the 

\}  The  oesopliaarus  must  be  closed  by  placing;  the  thumb  and  fingers  on  either  side  of 
the  larynx  and  pressing  it  back,  or  you  will  inflate  the  stomach  instead  of  the  lungs. — 

p:d.] 


MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETC.  559 

bath.  Nurses  are  apt  to  use  undue  roughness  in  endeavoring  to  remove 
every  particle  of  the  vernix  caseosa,  small  portions  of  which  are  often 
firmly  adherent.  This  mistake  should  be  avoided,  as  these  particles  will 
soon  dry  up  and  become  spontaneously  detached.  The  cord  is  generally 
wrapped  in  a  small  piece  of  cliarred  linen,  which  is  supposed  to  have 
some  slight  antiseptic  property,  and  this  is  renewed  from  day  to  day 
until  the  cord  has  withered  and  separated.  This  generally  occurs  within 
a  week,  and  a  small  pad  of  soft  linen  is  then  placed  over  the  umbilicus, 
and  supported  by  a  flannel  belly-baild  placed  round  the  abdomen,  which 
should  not  be  too  tight,  for  fear  of  embarrassing  the  respiration.  By 
this  means  the  tendency  to  umbilical  hernia  is  prevented.  [As  the  ver- 
nix caseosa  is  readily  miscible  with  pure  lard,  and  can  be  easily  removed 
by  its  means,  it  has  become  the  practice  with  many  obstetricians  in  the 
United  States  to  order  the  infant  to  be  well  anointed,  and  then  wiped 
from  head  to  foot  Avith  soft  rags,  until  all  the  vernix  disappears,  and  the 
skin  retains  a  slight  oily  trace,  not  enough  to  soil  the  clothing.  By  this 
means  water  is  avoided,  and  with  it  much  of  the  risk  of  taking  cold,  and 
the  skin  is  left  less  sensitive  after  the  sudden  change  M'hich  it  is  made  to 
endure  at  birth  than  when  subjected  to  hot  water  and  soap.  In  the  hot 
months  water  is  preferable  at  the  first  dressing. — Ed.] 

Clothing,  etc. — The  clothing  of  the  infant  varies  according  to  fashion 
and  the  circumstances  of  the  parents.  The  important  points  to  bear 
in  mind  are  that  it  should  be  warm  (since  newly-born  children  are  ex- 
tremely susceptible  to  cold),  and  at  the  same  time  light  and  sufficiently 
loose  to  allow  free  play  to  the  limbs  and  thorax.  All  tight  bandaging 
and  swaddling,  such  as  is  so  common  in  some  parts  of  the  Continent, 
should  be  avoided,  and  the  clothes  should  be  fastened  by  strings  or  by 
sewing,  and  no  pins  used.  At  the  present  clay  it  is  customary  not  to  use 
caps,  so  that  tlie  head  may  be  kept  cool.  The  utmost  possible  attention 
should  be  paid  to  cleanliness,  and  the  child  should  be  regularly  bathed 
in  tepid  water — at  first  once  daily,  and  after  the  first  few  weeks  both 
night  and  morning.  After  drying,  the  flexures  of  the  thighs  and  arms 
and  the  nates  should  be  dusted  with  violet  powder  or  fuller's  earth,  to 
prevent  chafing  of  the  skin.  The  excrements  should  be  received  in  nap- 
kins wrapped  round  the  hips,  and  great  care  is  required  to  change  the 
napkins  as  often  as  they  are  wet  or  soiled,  otherwise  troublesome  irrita- 
tion ^vill  arise.  A  neglect  of  this  precaution  and  the_washiiig_Qfjthe 
na|)kins_3ath_coaTse^oa[^^  are  among  the  principal  causes  of  the 

eru])ti()ns  and  excoriations  so  common  in  badly  cared-for  children.  When 
washed  and  dressed  the  child  may  be  placed  in  its  cradle  and  covered 
with  soft  blankets  or  an  eider-down  quilt. 

Ajyplmdlon  of  the  Child  to  the  Bread. — As  soon  as  tlie  motlier  has 
rest(;d  a  little  it  is  advisable  to  place  the  child  to  the  breast.  Tliis  is 
useful  to  the  mother  l)y  favoring  uterine  contrac^tion.  Even  now  therej 
is  in  the  breasts  a  variable  (piantity  of  the  peculiar  fluid  known  as  co- 
lodrum.  This  is  a  viscid  yellowish  secretion,  diflPerent  in  appeai'ance 
from  the  thin  bluish  milk  which  is  subsequently  formed.  Examined 
under  the  mic^rosc^ojU',  it  is  found  to  contain  some  milk-globules  and  a 
number  of  large  gramilar  and  small  fat-c(»rj)uscles.  It  has  a  ])urgatiye 
])i;o|)erty.,  and  soon  produces,  with   less  irritation  than  any  of  the  laxa- 


660  THE  PUERPERAL  STATE. 

tives  so  generally  used,  a  discharge  of  the  meconium  with  which  the 
bowels  are  loaded.  Hence  the  accoucheur  should  prohibit  the  common 
practice  of  administering  castor  oil  or  other  aperient  within  the  first  few 
days  after  birth,  although  there  can  be  no  objection  to  it  in  special  cases 
if  the  bowels  appear  to  act  inefficiently  and  ^vith  difficulty. 

I  Over-frequent  Suckling  should  be  Avoided. — For  the  first  few  days, 
and   until  the  secretion  of  milk  is  thoroughly  established,  the  child 

j  should  be  put  to  the  breast  at  long  intervals  only.  Constant  attempts 
at  sucking  an  empty  breast  lead  to  nothing  but  disappointment,  both  to 
the  mother  and  child,  and,  by  unduly  irritating  the  mammae,  sometimes 

j  to  positive  harm.  Therefore,  for  the  first  day  or  two  it  is  sufficient  if  the 
child  be  applied  to  the  breast  twice,  or  at  most  three  times,  in  the  tvventy- 

jjbur  hours.  Nor  is  it  necessary  to  be  apprehensive,  as  many  mothers 
naturally  are,  that  the  child  will  suffer  from  want  of  food.  A  few  spoon- 
fuls of  milk  and  water  being  given  from  time  to  time,  the  child  may 
generally  wait  without  injury  until  the  milk  is  secreted.  .  This  is  gen- 
erally about  the  third  day,  when  the  secretion  is  found  to  be  a  whitish 
fluid,  more  watery  in  appearance  than  cow's  milk,  and  showing  under 
the  microscope  an  abundance  of  minute  spherical  globules,  refracting 
light  strongly,  which  are  abundant  in  proportion  to  the  quality  of  the 
milk.  A  certain  number  of  granular  corpuscles  may  also  be  observed 
shortly  after  the  birth  of  the  child,  but  after  the  first  month  these  should 
have  almost  altogether  disappeared.  The  reaction  of  human  milk  is 
decidedly  alkaline,  and  the  taste  much  sweeter  than  that  of  cow's  milk. 
Importance  of  Nursing  when  Practicable. — The  importance  to  the 
mother  of  nursing  her  own  child  whenever  her  health  permits,  on 
account  of  the  favorable  influence  of  lactation  in  promoting  a  proper 
involution  of  the  uterus,  has  already  been  insisted  on.  Unless  there  be 
some  positive  contraindication,  such  as  a  marked  strumous  cachexia,  an 
hereditary  phthisical  tendency,  or  great  general  debility,  it  is  the  duty 
of  the  accoucheur  to  urge  the  mother  to  attempt  lactation,  even  if  it  be 
not  carried  on  more  than  a  month  or  two.  It  is,  however,  the  fact  that 
in  the  upper  classes  of  society  a  large  number  of  patients  are  unable  to 
nurse,  even  though  Mailing  and  anxious  to  do  so.  In  some  there  is 
hardly  any  lacteal  secretion  at  all ;  in  others  there  is  at  first  an  over- 
abundance of  watery  and  innutritions  milk,  which  floods  the  breasts  and 
soon  dies  away  altogether. 

When  the  llother  cannot  Nurse,  a  Wet-nurse  shoidd  be  Procured. — 
Whenever  the  mother  cannot  or  will  not  nurse  the  question  will  arise  as 
to  the  method  of  bringing  up  the  child.  From  many  causes  there  is  an 
increasing  tendency  to  resort  to  bottle-feeding,  instead  of  procuring  the 
services  of  a  wet-nurse,  even  when  the  question  of  expense  does  not 
come  into  consideration.  No  long  experience  is  required  to  prove  that 
hand-feeding  is  a  bad  and  imperfect  substitute  for  nature's  mode,  and 
one  which  the  practitioner  should  discourage  whenever  it  lies  in  his 
power  to  do  so.  It  is  true  that  in  many  cases  bottle-fed  children  do 
well,  but  there  is  good  reason  to  believe  that,  even  when  apparently 
most  successful,  the  children  are  not  so  strong  in  after-life  as  they  would 
have  been  had  they  been  brought  up  at  the  breast.  When,  in  addition, 
it  is  borne  in  mind  how  much  of  the  success  of  hand-feeding  depends 


MANAGEMENT  OF  THE  INFANT,   LACTATION,   ETC. 


561 


on  intelligent  care  on  the  part  of  the  nurse,  what  evils  are  apt  to  accrue 
from  the  injurious  selection  of  the  food  and  from  ignorance  of  the  com- 
monest laws  of  dietetics,  there  is  abundant  reason  for  urging  the  substi- 
tution of  a  wet-nurse  whenever  the  mother  is  unable  to  undertake  the 
suckling  of  her  child.  It  must  be  admitted  that  good  hand-feeding  is 
better  than  bad  wet-nursing,  and  the  success  of  the  latter  hinges  on  the 
proper  selection  of  a  wet-nurse.  As  this  falls  within  the  duties  of  the 
practitioner,  it  will  be  well  to  point  out  the  qualities  which  should  be 
sought  for  in  a  wet-nurse,  before  proceeding  to  discuss  the  mode  of  rear- 
ing the  child  at  the  breast. 

Selection  of  a  Wet-nurse. — In  selecting  a  wet-nurse  we  should  endeavor 
to  choose  a  strong,  healthy  woman,  who  should  not  be  over  30,  or  35 
years  of  age  at  the  outside,  since  the  quality  of  the  milk  deteriorates  in 
women  who  are  more  advanced  in  life.  For  a  similar  reason  a  very 
young  woman  of  16  or  17  should  be  rejected.  It  is  needless  to  say  that 
care  must  be  taken  to  ascertain  the  absence  of  all  traces  of  constitutional 
disease,  especially  marks  of  scrofula  or  enlarged  cervical~or~mguinal 
glands,  which  may  possibly  be  due  to  antecedent  syphilitic_taint.  If 
the  nurse  be  of  good  muscular  development,  healthy-looking,  with  a 
clear  complexion,  and  sound  teeth  (indicating  a  generally  good  state  of 
health),  the  color  of  the  hair  and  eyes  is  of  secondary  importance.  It  is 
commonly  stated  that  brunettes  make  better  nurses  than  blondes,  but 
this  is  by  no  means  necessarily  the  case,  and,  provided  all  the  other 
points  be  favorable,  fairness  of  skin  and  hair  need  be  no  bar  to  the  selec- 
tion of  a  nurse.  The  breajte^  should  be  pear-shaped,  i;;ather^ir|n^  as 
indicating  an  abundance  of  gland-tissue,  and  with  the  sujDerficial  veins 
well  marked.  Large,  flabby  breasts  owe  much  of  their  size  to  an  undue 
deposit  of  fat,  and  are  generally  unfavorable.  Thejiipple  should  be 
proinhient,  not  too^large,^  and  free  from  cracks  and  erosions,  which,  if 
existing,  might  lead  to  subsequent  difficulties  in  nursing.  On  pressing 
the  breast  the  milk  should  flow  from  it  easily  in  a  number  of  small  jets, 
and  some  of  it  should  be  preserved  for  examination.  It  should  be  of  a 
bluish-white  color,  and  when  placed  under  the  microscope  the  field 
should  be  covered  with  an  abundance  of  milk-corpuscles  and  the  large 
granular  corpuscles  of  the  colostrum  should  have  entirely  disappeared. 
If  the  latter  be  observed  in  any  quantity  in  a  woman  who  has  been  con-" 
fined  five  or  six  weeks,  the  inference  is  that  the  milk  is  inferior  in  quality. 
It  is  not  often  that  the  practitioner  has  an  opportunity  of  inquiring  into 
the  moral  qualities  of  the  nurse,  although  much  valuable  information 
might  be  derived  from  a  knowledge  of  her  previous  character.  An 
irascible,  excitable,  or  highly-nervous  woman  will,  certainly  make  a  bad 
nurse,  and  the  most  trivial  causes  might  afterward  interfere  with  the 
lier  milk.  Particular  attention  should  be  paid  to  the  nurse's 
since  its  condition  affords  the  best  criterion  of  the  quality  of 
It  should  b(;  plump,  well-nourished,  and  free  from  all  blem- 
islic-;.  If  it  be  at  all  thin  and  wizened,  especially  if  there  be  any  snuf- 
fling at  the  nose,  or  should  any  eruption  exist  affording  the  slightest  sus- 
j)i(Mon  of  a  syphilitic;  taint,  the  nurse  should  bo  unhesitatingly  rejected. 

Mdnaf/cment  of  Hnck/inf/. — "^riK!  nKinngctucnt  of  suckling  is  nnich  the'' 
same  whether  the  child  is  nursed  by  the  mother  or  by  a  wet-jmrse.     As 
36 


quality  of 
own  child 
her  milk. 


562  THE  PUERPERAL  STATE. 

soon  as  the  supply  of  milk  is  sufficiently  established,  the  child  must  be 
put  to  the  breast  at  short  intervals — ^ai^first  of"  about  two  hours,  and  in 
about  a  month  or  six  weeks  of  three  hours.  From  the  first  few  days  it 
is  a  matter  of  the  greatest  importance,  both  to  the  mother  and  child,  to 
a^C[uire  regular  habits  in  this  respect.  If  the  mother  get  into  the  way 
of  allowing;  the  infant  to  take  the  breast  whenever  it  cries  as  a  means 
of  keeping  it  quiet,  her  own  health  must  soon  suffer,  to  say  nothing  of 
the  discomfort  of  being  incessantly  tied  to  the  child's  side ;  while  the 
child  itself  has  not  sufficient  rest  to  digest  its  food,  and  very  shortly  diar- 
rh(pa  or  other  symptoms  of  dyspepsia  are  pretty  sure  to  follow%  After 
a  month  or  two  the  infant  should  be  trained  to  require  the  breast  less 
often  at  night,  so  as  to  enable  the  mother  to  have  an  undisturbed  sleep 
of  six  or  seven  hours.  For  this  purpose  she  should  arrange  the  times 
of  nursing  so  as  to  give  the  breast  just  before  she  goes  to  bed,  and  not 
again  until  the  early  morning.  If  the  child  should  require  food  in  the 
interval,  a  little  milk  and  water  from  the  bottle  may  be  advantageously 
given. 

Diet  of  Nursing  Women. — The  diet  of  the  nursing  woman  should  be 
arranged  on  ordinary  principles  of  hygiene.  It  should  be  abundant, 
simple,  and  nutritious,  but  all  rich  and  stimulating  articles  of  food 
should  be  avoided.  A  common  error  in  the  diet  of  wet-nurses  is  over- 
feeding, which  constantly  leads  to  deterioration  of  the  milk.  Many  of 
these  women  before  entering  on  their  functions  have  been  living  on  the 
simplest  and  even  sparest  diet,  and  not  uncommonly,  in  the  better  class 
of  houses,  they  are  suddenly  given  heavy  meat  meals  three  and  even 
four  times  a  day,  and  often  three  or  four  glasses  of  stout.  It  is  hardly 
a  matter  of  astonishment  that  under  such  circumstances  their  milk  should 
be  found  to  disagree.  For  a  nursing  woman  in  good  health  two  good 
meat  meals  a  day,  with  two  glasses  of  beer  or  porter,  and  as  much  milk 
and  bread  and  butter  as  she  likes  to  take  in  the  intervals,  should  be 
amply  sufficient.  Plenty  of  moderate  exercise  should  be  taken,  and  the 
more  nurse  and  child  are  out  in  the  open  air,  provided  the  weather  be 
reasonably  fine,  the  better  it  is  for  both.  [As  a  rule,  American  wet- 
nurses  have  been  much  better  fed  than  those  here  described,  and  have 
not  been  in  the  habit  of  using  malt  drinks.  A  healthy  woman  will 
usually  nurse  well  on  her  ordinary  diet,  which  should  be  largely  farina- 
ceous. If  she  can  drink  milk,  there  is  nothing  equal  to  it  in  furnishing 
a  lacteal  supply. — Ed.] 

Signs  of  Saccessful  Lactation. — Carried  on  methodically  in  this  man- 
ner, wet-nursing  should  give  but  little  trouble.  In  the  intervals  between 
its  meals  the  child  sleeps  most  of  its  time,  and  wakes  with  regularity  to 
feed ;  but  if  the  child  be  wakeful  and  restless,  cry  after  feeding,  have 
disordered  bowels,  and,  above  all,  if  it  do  not  gain  week  by  week  in 
weight  (a  point  which  should  be  from  time  to  time  ascertained  by  the 
scales),  we  may  conclude  that  there  is  either  some  grave  defect  in  the 
management  of  suckling  or  that  the  milk  is  not  agreeing.  Should  this 
unsatisfactory  progress  continue  in  spite  of  our  endeavors  to  remedy  it, 
there  is  no  resource  left  but  the  alteration  of  the  diet,  either  by  chang- 
ing the  nurse  or  by  bringing  up  the  child  by  hand.  The  former  should 
be  preferred  whenever  it  is  practicable,  and  in  the  upper  ranks  of  life  it 


MANAGEMENT  OF  THE  INFANT,   LACTATION,   ETC.  563 

is  by  no  means  rai^e  to  have  to  change  the  wet-nurse  two  or  three  times 
before  one  is  met  with  whose  milk  agrees  perfectly.  If  the  child  have 
reached  six  or  seven  months  of  age,  it  may  be  preferable  to  wean  it  alto- 
gether, especially  if  the  mother  have  nursed  it,  as  hand-feeding  is  much 
less  objectionable  if  the  infant  have  had  the  breast  for  even  a  few 
months. 

Period  of  Weaning. — As  a  rule,  weaning  should  not  be  attempted 
until  dentition  is_fairly  established,  that  being  the  sign  that  nature  has 
prepared  the  child  for  an  alteration  of  food ;  and  it  is  better  that  the 
main  portion  of  the  diet  should  be  breast  milk  until  at  least  six  or  seven 
teeth  have  appeared.  This  is  a  safer  guide  than  any  arbitrary  rule  taken 
from  the  ao;e  of  the  child,  since  the  commencement  of  dentition  varies 
much  in  different  cases.  About  the  sixth  or  seventh  month  it  is  a  good 
plan  to  commence  the  use  of  some  suitable  artificial  food  once  a  day,  so 
as  to  relieve  the  strain  on  the  mother  or  nurse  and  prepare  the  child  for 
weaning,  which  should  always  be  a  very  gradual  process.  In  this  way 
a  meal  of  rusks  of  the  entire  wheat  flour,  or  of  beef-  or  chicken-tea  with 
bread-crumb  in  it,  may  be  given  with  advantage ;  and  as  the  period  for 
weaning  arrives  a  second  meal  may  be  added,  and  so  eventually  the 
cliild  may  be  weaned  without  distress  to  itself  or  trouble  to  the  nurse. 

The  Disorders  of  Laotcdion. — The  disorders  of  lactation  are  numer- 
ous, and,  as  they  frequently  come  under  the  notice  of  the  practitioner,  it 
is  necessary  to  allude  to  some  of  the  most  common  and  important. 

Means  of  Arresting  the  Secretion  of  3Iilk. — The  advice  of  the  accouch- 
eur is  often  required  in  cases  in  which  it  has  been  determined  that  the 
patient  is  not  to  nurse,  when  we  desire  to  get  rid  of  the  milk  as  soon  as 
possible,  or  when,  at  the  time  of  weaning,  the  same  object  is  sought. 
The  extreme  heat  and  the  distension  of  the  breasts  in  the  former  class  of 
cases  often  give  rise  to  much  distress.  A  smart  saline  aperient  will  aid 
in  removing  the  milk,  and  for  this  purpose  a  double  Seidlitz  powder  or 
frequent  small  doses  of  sulphate  of  magnesia  act  well,  while,  at  the  same 
time,  the  patient  should  be  advised  to  take  as  small  a  quantity  of  fluid 
as  possible.  Iodide  of  potassium  in  large  doses  of  20  or  25  grains,  ^ 
repeated  twice  or  thrice,  has  a  remarkable  efl^ect  in  arresting  the  secretion 
of  milk.  This  observation  was  first  empirically  made  by  observing  that— 
the  secretion  of  milk  was  arrested  when  this  drug  was  administered  for 
some  other  cause  ;  and  I  have  frequently  found  it  answer  remarkably 
well.  The  distension  of  the  breasts  is  best  relieved  by  covering  them 
with  a  layer  of  lint  or  cotton  wool  soaked  in  a  spirit  lotion  or  eau  de 
C'ologiK!  and  water,  over  which  oiled  silk  is  placed,  and  by  directing  the 
iiui'se  to  juJ)  them^ently  with  warm  oil  whenever  they  get  hard  and  ^  th.-^% 
hunpy.  Breast-j)umps  and  similar  contrivances  only  irritate  the  breasts,  y^^i^^^U- 
aiid  (io  more  harm  than  good.  Tlie  local  application  of  belladonna  has  ^T'^'T^ 
been  strongly  reciommended  as  a  means  for  preventing  lacteal  secretion. 
As  usually  applied,  in  the  form  of  belladonna  plaster,  it  is  likely  to 
prove  hurtful,  since  the  breast  often  enlarges  after  the  plasters  are 
a])pH(!(l,  and  the  pressui'c  of  the  unyielding  leather  on  which  th(\y  are 
s[)rea<l  j)rodiices  intense  suffering.  A  better  way  of  using  it  is  l)y  rub- 
bing dc>wn  a  draclnn  oi'  tli(!  (extract  of  bcHadonnii,  with  an  ounce  of 
glycerin  and  applying  this  on  lint.      In  some  cases  it  answers  extremely 


]0. 


564  THE  PUERPERAL  STATE. 

well,   but   it  is   veiy  uncertain  in   its  action,   and    frequently  is  quite 
useless. 

Defective  Secretion  of  Milk. — A  deficiency  of  milk  in  nursing  mothers 
is  a  very  common  source  of  difficulty.  In  a  Avet-nurse  this  drawback  is, 
of  course,  an  indication  for  changing  the  nurse ;  but  to  the  mother  the 
importance  of  nursing  is  so  great  that  an  endeavor  must  be  made  either 
to  increase  the  flow  of  milk  or  to  supplement  it  by  other  food.  Unfor- 
tunately, little  reliance  can  be  placed  on  any  of  the  so-called  galacta- 
f  gogues.  The  only  one  which  in  recent  times  has  attracted  attention  is 
the  leaves  of  the  castor-oil  plant,  which,  made  into  poultices  and  applied 
to  the  breast,  are  said  to  have  a  beneficial  effect  in  increasing  the  flow  of 
milk.  More  reliance  must  be  placed  in  the  sufficiency  of  nutritious 
food,  especially  such  as  contains  phosphatic  elements ;  stewed  eels,  oys- 
ters, and  other  kinds  of  shellfish,  and  the  Revalenta  Arabica,  are  recom- 
mended by  Dr.  Routh,  who  has  paid  some  attention  to  this  point,^  as 
\  peculiarly  appropriate.  If  the  amount  of  milk  be  decidedly  deficient, 
the  child  should  be  less  often  applied  to  the  breast,  so  as  to  allow  milk 
to  collect,  and  properly  prepared  cow's  milk  from  a  bottle  should  be 
given  alternately  with  the  breast.  This  mixed  diet  generally  answers 
well,  and  is  far  preferable  to  pure  hand-feeding.  [There  is  no  diet 
equivalent  to  milk  for  a  nursing  mother,  where  it  agrees  with  her.  This 
I  have  tested  repeatedly  in  %vomen  who  had  failed  entirely  in  former 
attempts  to  nurse  their  infants.  One  lady  who  had  lost  her  milk  three 
times  at  the  end  of  a  month,  and  had  nursed  two  babies  into  starvation, 
Avas  enabled  to  nurse  her  fourth  while  on  a  milk  diet  for  eighteen  months, 
and  gained  while  doing  so  19  pounds.  Another  gained  65  pounds  while 
nursing,  and  her  son  was  very  large  for  his  age.  A  third  lost  a  child 
by  hand-feeding,  and  nursed  the  next  infant  on  a  milk  diet,  at  the  same 
time  becoming  fatter  than  she  had  ever  been.  A  decided  advantage  in 
the  use  of  milk  is,  that  it  prevents  the  exhausted  feeling  so  common  with 
delicate  nursing  mothers.  I  have  had  a  patient  of  86  pounds  weight  use 
two  quarts  of  milk  a  day,  and  at  the  same  time  eat  her  usual  measure 
of  food,  which  had  always  been  of  small  amount. — Ed.] 
'  Depressed  Nipples. — A  not  uncommon  source  of  difficulty  is  a  depressed 
condition  of  the  nipples,  which  is  generally  produced  by  the  constant 
qjressure  of  the  stays.  The  result  i.s,  that  the  child,  unable  to  grasp  the 
nipple  and  wearied  with  ineffectual  efforts,  may  at  last  refuse  the  breast 
altogether.  An  endeavor  should  be  made  to  elongate  the  nipple  before 
putting  it  into  the  child's  mouth,  either  by  the  fingers  or  by  some  form 
of  breast-pump,  whicli  here  finds  a  useful  application.  In  the  worst 
class  of  cases,  when  the  nipple  is  permanently  depressed,  it  may  be 
necessary  to  let  the  child  suck  through  a  glass  nipple  shield  to  which  is 
attached  an  india-rubber  tube,  similar  to  that  of  a  sucking-bottle ;  this 
it  is  generally  well  able  to  do.  [In  some  instances  this  anatomical  defect 
appears  to  be  beyond  remedy,  unless  a  proposed  surgical  operation  can 
be  made  effective.  I  have  tried  to  pix^pare  primiparte  for  several  months 
before  labor,  and  then  failed  as  soon  as  the  breasts  filled  with  milk.  In 
some  cases  there  is  absolutely  no  nipple,  and  as  a  shield  is  of  no  value 
in  protection,  the  escaping  nplk  produces  an  eczema  over  the  waist  and 

'  Eoutli  on  Ivfant-J'eeding. 


MANAGEMENT  OF  THE  INFANT,  LACTATION,  ETO.  565 

upper  part  of  the  abdomen.    This  condition  I  have  seen  associated  with 
a  most  obstinate  galactorrhoea  lasting  several  months. — Ed.] 

Fissures  and  Excoriations  of  the  Nipples. — Fissures  and  excoriations 
of  the  nipples  are  common  causes  of  suifering,  in  some  cases  leading  to 
mammary  abscess.  Whenever  the  practitioner  has  the  opportunity,  he 
should  advise  his  patient  to  prepare  the  nipple  for  nursing  in  the  latter  j\v(fr>W^ 
months  of  pregnancy ;  and  this  may  best  be  done  by  daily  bathing  it  ^y^  -V^l 
with  a  spirituous  or  astringent  lotion,  such  as  eau  de  Cologne  and  water 
or  a  weak  solution  of  tannin.  After  nursing  has  begun  great  care  should 
be  taken  to  wash  and  dry  the  nipple  after  the  child  has  been  applied  to 
it,  and  as  long  as  the  mother  is  in  the  recumbent  position  she  may,  if 
the  nipples  be  at  all  tender,  use  zinc  nipple-shields  with  advantage  when  "V>^  <^ 
she  is  not  nursing.  In  this  way  these  troublesome  complications  may 
generally  be  prevented.  The  most  common  forms  are  either  an  abrasion 
on  the  surface  of  the  nipple,  which,  if  neglected,  may  form  a  small 
ulcer,  or  a  crack  at  some  part  of  the  nipple,  most  generally  at  its  base. 
In  either  case  the  suffering  when  the  child  is  put  to  the  breast  is  intense, 
sometimes  indeed  amounting  to  intolerable  anguish,  causing  the  mother 
to  look  forward  with  dread  to  the  application  of  the  child.  Whenever 
such  pain  is  complained  of,  the  nipple  should  be  carefully  examined, 
since  the  fissure  or  sore  is  often  so  minute  as  to  escape  superficial  examina- 
tion. The  remedies  recommended  are  very  numerous  and  not  always 
successful.  Amongst  those  most  commonly  used  are  astringent  applica- 
tions, such  as  tannin  or  weak  solutions  of  nitrate  of  silver,  or  cauteriz- 
ing the  edges  of  the  fissure  with  solid  nitrate  of  silver,  or  applying  the 
flexible  collodion  of  the  Pharmacopoeia.  Dr.  Wilson  of  Glasgow  speaks 
highly  of  a  lotion  composed  of  ten  grains  of  nitrate  of  lead  in  an  ounce 
of  glycerin,  which  is  to  be  applied  after  suckling,  the  nipple  being  care- 
fully washed  before  the  child  is  again  put  to  the  breast.  I  have  myself 
found  nothing  answer  so  well  as  a  lotion  composed  of  half  an  ounce  of 
sulphurous  acid,  half  an  ounce  of  the  glycerin  of  tannin,  and  an  ounce 
of  water,  the  beneficial  effects  of  which  are  sometimes  quite  remarkable. 
Helief  may  occasionally  be  obtained  by  inducing  the  child  to  suck 
through  a  nipple-shield,  especially  when  there  is  only  an  excoriation ; 
but  this  will  not  always  answer,  on  account  of  the  extreme  pain  which 
it  produces. 

Excessive  Flow  of  Milk. — An  excessive  flow  of  milk,  known  as  galac- 
torrhoea, often  interferes  with  successful  lactation.  It  is  by  no  means 
rare  in  the  first  weeks  after  delivery  for  women  of  delicate  constitution, 
who  are  really  unfit  to  nurse,  to  be  flooded  with  a  superabundance  of 
watery  and  innutritious  milk,  which  soon  produces  disordered  digestion 
in  the  child.  Under  such  circumstances  the  only  thing  to  be  done  is  to 
give  up  an  attempt  which  is  injurious  both  to  the  mother  and  child.  At 
a  later  stage  the  milk,  seca-eted  in  large  quantities,  is  sufficiently  nourish- 
ing to  th(!  child,  but  the  drain  on  the  mother's  constitution  soon  begins 
to  tell  on  her.  Pal])itatioii,  giddiness,  emaciiation,  headache,  loss  of 
slecj),  spots  before  the  eyes,  indi(^ate  tlie  serious  effects  whicdi  are  being 
produf;ed  and  the  absolute  necessity  of  at  once  stopping  lactation. 
Whenever,  therefore,  a  nursing  woman  suffers  from  such  symjitoms, 
it  is  far  better  at  once  to  remove  the  cause,  otherwise  a  very  serious  and 


566  THE  PUERPERAL  STATE. 

periiianent  deterioration  of  health  might  result.  When,  under  such  cir- 
cumstances, nursing  is  unwisely  persevered  in,  most  serious  results  may 
follow.  Should  any  diathetic  tendency  exist,  especially  when  there  is  a 
predisposition  to  phthisis,  nothing  is  so  likely  to  develop  it  as  the  debil- 
ity produced  by  excessive  lactation.  Certain  diseases  of  the  eye  are  then 
specially  apt  to  occur,  such  as  severe  inflammation  of  the  cornea,  leading 
to  opacity  and  even  sloughing,  and  certain  forms  of  choroiditis ;  also 
impairment  of  accommodation  due  to  defective  power  of  the  ciliary 
muscle.^ 

Mammary  Abscess. — There  is  no  more  troublesome  complication  of 
lactation  than  the  formation  of  abscess  in  the  breast — an  occurrence  by 
no  means  rare,  and  which,  if  improperly  treated,  may,  by  long-continued 
suppuration  and  the  formation  of  numerous  sinuses  in  and  about  the 
breast,  produce  very  serious  effects  on  the  general  health.     The  causes 
of  breast  abscesses  are  numerous,  and  very  trivial  circumstances  may 
occasionally  set  up  inflammation,  ending  in  suj)puration.     Thus  it  may 
follow  exposure  to  cold,  a  blow  or  other  injury  to  the  breast,  some  tem- 
porary engorgement  of  the  lacteal  tubes,  or  even  sudden  or  depressing 
I  mental  emotions.     The  most  frequent  cause  is  irritation  from  fissures  or 
'  erosions  of  the  nipples,  which  must  therefore  always  be  regaixled  A\ath 
[^suspicion,  and  cured  as  soon  as  possible. 

Signs  and  Symptoms. — The  abscess  may  form  in  any  part  of  the  breast 
or  in  the  areolar  tissue  below  it ;  in  the  latter  case  the  inflammation  very 
generally  extends  to  the  gland-structure.  Abscess  is  usually  ushered  in 
by  constitutional  symptoms,  varying  in  severity  with  the  amount  of  the 
inflammation.  Pyrexia  is  always  present ;  elevated  temperature,  rapid 
pulse,  and  much  malaise  and  sense  of  feverishness,  followed  in  many 
cases  by  distinct  rigor  when  deep-seated  suppuration  is  taking  place. 
On  examining  the  breast  it  will  be  found  to  be  generally  enlarged  and 
very  tender,  while  at  the  site  of  the  abscess  an  indurated  and  painful 
swelling  may  be  felt.  If  the  inflammation  be  chiefly  limited  to  the  sub- 
glandular  areolar  tissue,  there  may  be  no  localized  swelling  felt,  but  the 
whole  breast  will  be  acutely  sensitive  and  the  slightest  movement  will 
cause  much  pain.  As  the  case  progresses  the  abscess  becomes  more  and 
more  superficial,  the  skin  covering  it  is  red  and  glazed,  and  if  left  to  itself 
it  bursts.  In  the  more  serious  cases  it  is  by  no  means  rare  for  multiple 
abscesses  to  form.  These,  opening  one  after  the  other,  lead  to  the  forma- 
tion of  numerous  fistulous  tracts,  by  which  the  breast  may  become  com- 
pletely riddled.  Sloughing  of  portions  of  the  gland-tissue  may  take 
place,  and  even  considerable  hemorrhage  from  the  destruction  of  blood- 
vessels. The  general  health  soon  suffers  to  a  marked  degree,  and,  as 
the  sinuses  continue  to  suppurate  for  many  successive  months,  it  is  by 
no  means  uncommon  for  the  patient  to  be  reduced  to  a  state  of  profound 
and  even  dangerous  debility. 

Treatment. — Much  may  be  done  by  proper  care  to  prevent  the  forma- 
tion of  abscess,  especially  by  removing  engorgement  of  the  lacteal  ducts, 
when  threatened,  by  gentle  hand-friction  in  the  manner  already  indi- 

^  See  Foerster  of  Breslau  in  Graefe  and  Saemisch's  Handhuch  des  Gesammien  Augeri- 
heilkunde,  and  Power  on  "  The  Diseases  of  the  Eye  in  Connection  with  Pregnancy," 
Lancet,  May  8,  1880,  et  seq. 


MANAGEMENT  OF  THE  INFANT,   LACTATION,  ETC.  567 

cated.  When  the  general  symptoms  and  the  local  tenderness  indicate 
that  inflammtion  has  commenced,  M-e  should  at  once  endeavor  to  mod- 
erate it,  in  the  hope  that  resolution  may  occur  without  the  formation  of 
pus.  Here  general  principles  must  be  attended  to,  especially  giving  the 
aifected  part  as  much  rest  as  possible.  Feverishness  may  be  combated 
by  gentle  salines,  minute  doses  of  aconite,  and  large  doses  of  quinine, 
while  pain  shoidd  be  relieved  by  opiates.  The  patient  should  be  strictly 
confined  in  bed,  and  the  affected  breast  supported  by  a  suspensory  band- 
age. Warmth  and  moisture  are  the  best  means  of  relieving  the  local 
pain,  either  in  the  form  of  liot  fomentations  or  of  light  poultices  of  lin- 
seed meal  or  bread  and  milk,  and  the  breast  may  be  smeared  with 
extract  of  belladonna  rubbed  down  with  glycerin,  or  the  belladonna 
liniment  sprinkled  over  the  surface  of  the  poultices.  The  local  appli- 
cation of  ice  in  india-rubber  bags  has  been  highly  extolled  as  a  means 
of  relieving  the  pain  and  tension,  and  is  said  to  be  much  more  effectual 
than  heat  and  moisture.^  Generally,  the  pain  and  irritation  produced  by 
putting  the  child  to  the  breast  are  so  great  as  to  contraindicate  nursing" 
from  the  affected  side  altogether,  and  we  must  trust  to  relieving  the 
tension  by  poultices,  suckling  being  in  the  mean  time  carried  on  by  the 
other  breast  alone.  In  favorable  cases  this  is  quite  possible  for  a  time, 
and  it  may  be  that,  if  the  inflammation  do  not  end  in  suppuration  or  if 
the  abscess  be  small  and  localized,  the  affected  breast  is  again  able  to 
resume  its  functions.  Often  this  is  not  possible,  and  it  may  be  advisable 
in  severe  cases  to  give  up  nursing  altogether. 

Pus  should  be  Removed  as  80071  as  Possible. — The  subsequent  manage- 
ment of  the  case  consists  in  the  opening  of  the  abscess  as  soon  as  the 
existence  of  pus  is  ascertained,  either  by  fluctuation  or,  if  the  site  of  the 
abscess  be  deep  seated,  by  the  exploring-needle.  It  may  be  laid  down 
as  a  principle  that  the  sooner  the  pus  is  evacuated  the  better,  and  noth- 
ing is  to  be  gained  by  waiting  until  it  is  superficial.  On  the  contrary, 
such  delay  only  leads  to  more  extensive  disorganization  of  tissue  and  the 
furtlier  spread  of  inflammation. 

Antiseptic  Treatment  of  Mammary  Abscess. — The  method  of  opening 
the  abscess  is  of  primary  importance.  It  has  always  been  customary 
simply  to  open  the  abscess  at  its  most  dependent  part,  without  using 
any  precaution  against  the  admission  of  air,  and  afterward  to  treat 
secondary  abscesses  in  the  same  way.  The  results  are  well  known  to  all 
practical  accoucheurs,  and  the  records  of  surgery  fully  show  how  many 
weeks  or  montlis  generally  elapse  in  bad  cases  before  recovery  is  com- 
]>l('tc.  The  antiseptic  treatment  of  mammary  abscess,  in  the  way  first 
])ointcd  out  by  Ijister,  aflbrds  resuhs  wliich  are  of  the  most  remarkable 
and  satisfactory  kind.  Instead  of  being  weeks  and  months  in  healing, 
I  believe  that  the  practitioner  who  fairly  and  minutely  carries  out  Sir 
Joseph  Lister's  directions  may  confidently  look  for  complete  closure  of 
the  abscess  in  a  few  days ;  and  I  know  of  nothing  in  the  whole  range 
of  my  professional  experience  that  has  given  me  more  satisfaction  than 
the  a])plication  of  this  nictlutd  to  abscesses  of  the  breast.  The  ])lan  I 
first  used  is  that  reconniiendcd  by  Ijistci-  in  tlw  Lancet  for  IHGT,  but 
which  is  n(nv  superseded  by  his  iinpi-ovcd  methods,  which  of  course  will 

'  Carson,  Amer.  Jovrn.  <if  Obxicl.,  .Tan.,  1881. 


568  THE  PUERPERAL  STATE. 

be  used  in  preference  by  all  who  have  made  themselves  familiar  with 
the  details  of  antiseptic  surgery.  The  former,  however,  is  easily  within 
the  reach  of  every  one,  and  is  so  simple  that  no  special  skill  or  practice 
is  required  in  its  application,  whereas  the  more  perfected  antiseptic  ap- 
pliances \\'\\\  probably  not  be  so  readily  obtained  and  are  much  more 
diflicult  to  use.  I  therefore  insert  Sir  Joseph  Lister's  original  direc- 
tions, which  he  assures  me  are  perfectly  antiseptic,  for.  the  guidance  of 
those  who  may  not  be  able  to  obtain  the  more  elaborate  dressings  :  ''A 
solution  of  one  part  of  crystallized  carbolic  acid  in  four  parts  of  boiled 
linseed  oil  having  been  prepared,  a  piece  of  rag  from  four  to  six  inches 
square  is  dipped  into  the  oily  mixture  and  laid  upon  the  skin  where  the 
incision  is  to  be  made.  The  lower  edge  of  the  rag  beinsr  then  raised 
while  the  upper  edge  is  kept  from  slipping  by  an  assistant,  a  common 
scalpel  or  bistoury  dipped  in  the  oil  is  plunged  into  the  cavity  of  the 
abscess,  and  an  opening  about  three-quarters  of  an  inch  in  length  is 
made ;  and  the  instant  the  knife  is  withdrawn  the  rag  is  dropped  upon 
the  skin  as  an  antiseptic  curtain,  beneath  wdiich  the  pus  flows  out  into  a 
vessel  placed  to  receive  it.  The  cavity  of  the  abscess  is  fii-mly  pressed, 
so  as  to  force  out  all  existing  pus  as  nearly  as  may  be  (the  old  fear  of 
doing  mischief  by  rough  treatment  of  the  pyogenic  membrane  being 
quite  ill-founded) ;  and  if  there  be  much  oozing  of  blood,  or  if  there  be 
considerable  thickness  of  parts  between  the  abscess  and  the  surface,  a 
piece  of  lint  dipped  in  the  antiseptic  oil  is  introduced  into  the  incision  to 
check  bleeding  and  prevent  primary  adhesion,  wdiich  is  otherwise  very 
apt  to  occur.  The  introduction  of  the  lint  is  eifected  as  rapidly  as  may 
be,  and  under  the  protection  of  the  antiseptic  rag.  Thus  the  evacuation 
of  the  original  contents  is  accomplished  with  perfect  security  against  the 
introduction  of  living  germs.  This,  however.  Mould  be  of  no  avail  un- 
less an  antiseptic  dressing  could  be  applied  that  would  eifectually  prevent 
the  decomposition  of  the  stream  of  pus  constantly  flowing  out  beneath  it. 
After  numerous  disappointments  I  have  succeeded  with  the  following, 
which  may  be  relied  upon  as  absolutely  trustworthy :  About  six  tea- 
spoonfuls  of  the  above-mentioned  solution  of  carbolic  acid  in  linseed 
oil  are  mixed  up  with  common  whiting  (carbonate  of  lime)  to  the  con- 
sistence of  a  firm  paste,  which  is,  in  fact,  glazier's  putty  with  the  addi- 
tion of  a  little  carbolic  acid.  This  is  spread  upon  a  piece  of  common 
tin-foil  about  six  inches  square,  so  as  to  form  a  layer  about  a  quarter  of 
an  inch  thick.  The  tin-foil,  thus  spread  with  putty,  is  placed  upon  the 
skin  so  that  the  middle  of  it  corresponds  to  the  position  of  the  incision, 
the  antiseptic  rag  used  in  opening  the  abscess  being  removed  the  instant 
before.  The  tin  is  then  fixed  securely  by  adhesive  plaster,  the  lowest 
edge  being  left  free  for  the  escape  of  the  discharge  into  a  folded  towel 
placed  over  it  and  secured  by  a  bandage.  The  dressing  is  changed,  as  a 
general  rule,  once  in  twenty-four  hours,  but  if  the  abscess  be  a  very 
large  one  it  is  ]:)rudent  to  see  the  patient  twelve  hours  after  it  has  been 
opened,  Avlien,  if  the  towel  should  be  much  stained  with  discharge,  the 
dressing  should  be  changed,  to  avoid  subjecting  its  antiseptic  virtues  to 
too  severe  a  test.  But  after  the  first  twenty-four  hours  a  single  daily 
dressing  is  sufficient.  The  changing  of  the  dressing  must  be  method- 
ically done,  as  follows  :  A  second  similar  piece  of  tin-foil  having  been 


MANAGEMENT  OF  THE  INFANT,   LACTATION,  ETC.  569 

spread  with  the  putty,  a  piece  of  rag  is  dipped  in  the  oily  sohition  and 
placed  on  the  incision  the  moment  the  first  tin.  is  removed.  This  guards 
against  the  possibility  of  mischief  occurring  during  the  cleansing  of  the 
skin  with  a  dry  cloth  and  pressing  out  any  discharge  which  may  exist 
in  the  cavity.  If  a  plug  of  lint  was  introduced  when  the  abscess  was 
opened,  it  is  removed  under  cover  of  the  antiseptic  rag,  which  is  taken 
off  at  the  moment  when  the  new  tin  is  to  be  applied.  The  same  process 
is  continued  daily  until  the  sinus  closes." 

Treatment  of  Long-continued  Suppuration  and  Fever. — If  the  case 
come  under  our  care  when  the  abscess  has  been  long  discharging  or 
when  sinuses  have  formed,  the  treatment  is  directed  mainly  to  procuring 
a  cessation  of  suppuration  and  closure  of  the  sinuses.  For  this  purpose 
methodical  strapping  of  the  breast  with  adhesive  plaster,  so  as  to  afford 
steady  support  and  compress  the  composing  pyogenic  surfaces,  will  give 
the  best  results.  It  may  be  necessary  to  lay  open  some  of  the  sinuses, 
or  to  inject  tinct.  iodi  or  other  stimulating  lotions  so  as  to  moderate  the 
discharge,  the  subsequent  surgical  treatment  varying  according  to  the 
requirements  of  each  case.  In  such  neglected  cases  Billroth  recom- 
mends that  after  the  patient  has  been  anaesthetized  the  openings  should 
be  dilated  so  as  to  admit  the  finger,  by  which  the  septa  between  the  vari- 
ous sinuses  should  be  broken  down  and  a  large  single  abscess-cavity 
made.  This  should  then  be  thoroughly  irrigated  with  a  3  per  cent, 
solution  of  carbolic  acid,  a  drainage-tube  introduced,  and  the  ordinary 
antiseptic  dressings  applied.  As  the  drain  on  the  system  is  great  and 
the  constitutional  debility  generally  pronounced,  much  attention  must  be 
paid  to  general  treatment,  and  abundance  of  nourishing  food,  appropri- 
ate stimulants,  and  such  medicines  as  iron  and  quinine  will  be  indicated. 

Hand-Feeding. — In  a  considerable  number  of  cases  the  inability  of 
the  mother  to  nurse  the  child,  her  invincible  repugnance  to  a  wet-nurse, 
or  inability  to  bear  the  expense  renders  hand-feeding  essential.  It  is 
therefore  of  importance  that  the  accoucheur  should  be  thoroughly  famil- 
iar with  the  best  method  of  bringing  up  the  child  by  hand,  so  as  to  be 
able  to  direct  the  process  in  the  way  that  is  most  likely  to  be  successful. 

Causes  of  Mortality  in  Hand-fed  Children. — Much  of  the  mortality 
following  hand-feeding  may  be  traced  to  unsuitable  food.  Among  the 
poorer  classes  especially  there  is  a  prevalent  notion  that  milk  alone  is 
insufficient,  and  hence  the  almost  universal  custom  of  administering 
various  farinaceous  foods,  such  as  corn  flour  or  arrowroot,  even  from 
the  earliest  period.  Many  of  these  consist  of  starch  alone,  and  are 
therefore  absolutely  unsuitod  for  forming  the  staple  of  diet  on  account 
of  the  total  al)sence  of  nitrogenous  elements.  Independently  of  this,  it 
has  Ijeen  shown  that  the  saliva  of  infants  has  not  the  same  digestive 
])r(j[)erty  on  starch  that  it  subsequently  acquires,  and  this  affords  a  fur- 
ther explanation  of  its  so  constantly  producing  intestinal  derangement, 
lloason,  as  well  as  experience,  abinulantly  proves  that  the  object  to  be 
aimed  at  in  iiand-feeding  is  to  imitate  as  nearly  as  possible;  the  food 
wliich  nature  supj)]ics  for  tlu;  new-born  child,  and  tluireforc  the  obvious 
course  is  to  use;  milk  fi'om  some  animal,  so  treated  as  to  make  it  resemble 
human  milk  as  nearly  as  may  be. 

Ash's  Milk. — Of  the  various  milks  used,  that  of  the  ass,  on  the  whole, 


570  THE  PUERPERAL  STATE. 

most  closely  resembles  human  milk,  containing  less  casein  and  butter 
and  more  saline  ingredients.  It  is  not  always  easy  to  obtain,  and  in 
towns  is  excessively  expensive.  Moreover,  it  does  not  always  agree  with 
the  child,  being  ajit  to  produce  diarrhcea.  We  can,  however,  be  more 
certain  of  its  being  unadulterated,  which  in  large  cities  is  in  itself  no 
small  advantage,  and  it  may  be  given  without  the  addition  of  w^ater  or 
sugar. 

Goafs  3Iilk. — Goat's  milk  in  this  country  is  still  more  difficult  to 
obtain,  but  it  often  succeeds  admirably.  In  many  places  the  infant 
sucks  the  teat  directly,  and  certainly  thrives  well  on  the  plan. 

[We  reverse  the  order  in  this  country,  where  the  ass  is  seldom  seen 
and  the  goat  is  quite  common,  particularly  in  the  suburbs  of  our  large 
cities,  where  its  milk  is  most  required.  I  have  seen  marvellous  results 
from  feeding  sick  infants  with  its  milk  freshly  drawn  and  diluted  Avith 
hot  water.  I  do  not  believe  it  is  as  suitable  as  that  of  the  cow,  but  it 
has  the  advantage  that  it  can  be  obtained  freshly  drawn  in  a  city  by 
keeping  the  animal  in  the  yard  or  on  a  vacant  lot.  The  goat  should  be 
fed  upon  grass  and  other  suitable  diet,  and  not  permitted  to  run  at  large, 
.  <iw^<.  as  it  eats  with  impunity  stramonium  and  other  noxiousjvveeds. — Ed.] 
^♦♦^fn--  ^'^  Coiv's  3Iilk,  and  its  Preparation. — In  a  large  majority  of  cases  we 
have  to  rely  on  cow's  milk  alone.  It  differs  from  human  milk  in  con- 
taining less  water,  a  larger  amount  of  casein  and  solid  matters,  and  less 
sugar.  Therefore,  before  being  given  it  requires  to  be  diluted  and 
sweetened.  A  common  mistake  is  over-dilution,  and  it  is  far  from  rare 
for  nurses  to  administer  one-third  cow's  milk  to  two-thirds  water.  The 
result  of  this  excessive  dilution  is  that  the  child  becomes  pale  and  puny 
and  has  none  of  the  firm  and  plump  appearance  of  a  well-fed  infant. 
The  practitioner  should  therefore  ascertain  that  this  mistake  is  not  being 
made ;  and  the  necessary  dilution  will  be  best  obtained  by  adding  to 
pure  fresh  cojw^sjuiil3L.Qne=thkdJiot_water,  so  as  to  warm  the  mixture  to 
about  96°,  the  whole  being  slightly  sweetened  with  sugar  of  milk  or 
ordinary  crystallized  sugar.  After  the  first  two  or  three  months  the 
amount  of  water  may  be  lessened,  and  pure  milk,  warmed  and  sweet- 
ened, given  instead.  AVhenever  it  is  possible  the  milk  should  be  ob- 
tained from  the  same  cow,  and  in  towns  some  care  is  requisite  to  see  that 
the  animal  is  properly  fed  and  stabled.  Of  late  years  it  has  been  cus- 
tomary to  obviate  the  difficulties  of  obtaining  good  fresh  milk  by  using 
some  of  the  tinned  milks  now  so  easily  to  be  had.  These  are  already 
sweetened,  and  sometimes  answer  well  if  not  given  in  too  weak  a  dilu- 
tion. One  great  drawback  in  bottle-feeding  is  the  tendency  of  the  milk 
to  become  acid,  and  hence  to  produce  diarrhoea.  This  may  be  obviated 
to  a  great  extent  by  adding  a  tablespoonful  of  lime-water  to  each  bottle, 
instead  of  an  equal  quantity  of  water. 

[The  milk  of  the  Alderney  cow  contains  too  much  butter  to  make  a 
good  substitute  for  human  milk  in  feeding  young  infants,  and  will  often 
disagree  with  them  when  that  of  the  connnon  cow  will  be  digested. 
The  milk  of  one  cow,  which  should  neither  be  young  or  old,  is  to  be 
preferred,  but  it  must  be  borne  in  mind  that  the  special  osLXi  is  often  filled 
from  the  general  supply. — Ed.] 

Artificial  Human  3Iilk. — An  admirable  i)lan  of  treating  cow's  milk. 


MANAGEMENT  OF  THE  INFANT,   LACTATION,   ETC.  571 

so  as  to  reduce  it  to  almost  absolute  chemical  identity  with  human  milk, 
has  been  devised  by  Professor  Frankland,  to  whom  I  am  indebted  for 
permission  to  insert  the  recipe.  I  have  followed  this  method  in  many 
cases,  and  find  it  far  superior  to  the  usual  one,  as  it  produces  an  exact 
and  uniform  compound.  With  a  little  practice  nurses  can  employ  it 
with  no  more  trouble  than  the  ordinary  mixing  of  cow's  milk  with  water 
and  sugar.  The  following  extract  from  Dr.  Frankland's  work  ^  will 
explain  the  principles  on  which  the  preparation  of  the  artificial  human 
milk  is  founded  :  "  The  rearing  of  infants  who  cannot  be  supplied  with 
their  natural  food  is  notoriously  difficult  and  uncertain,  owing  chiefly  to 
the  great  difference  in  the  chemical  composition  of  human  milk  and 
cow's  milk.  The  latter  is  much  richer  in  casein  and  poorer  in  milk- 
sugar  than  the  former,  whilst  ass's  milk,  which  is  sometimes  used  for 
feeding  infants,  is  too  poor  in  casein  and  butter,  although  the  proportion 
of  sugar  is  nearly  the  same  as  in  human  milk.  The  relations  of  the 
three  kinds  of  milk  to  each  other  are  clearly  seen  from  the  following 
analytical  numbers,  which  express  the  percentage  amounts  of  the  different 
constituents : 

Woman.  Ass.  Cow. 

Casein ". 2.7  1.7  4.2 

Butter 3.5  1.3  3.8 

Milk-sugar 5.0  4.5  3.8 

Salts 2  .5  .7 

These  numbers  show  that  by  the  removal  of  one-third  of  the  casein  from 
cow's  milk,  and  the  addition  of  about  one-third  more  milk-sugar,  a 
liquid  is  obtained  which  closely  approaches  human  milk  in  composi- 
tion, the  percentage  amounts  of  the  four  chief  constituents  being  as  fol- 
lows : 

Casein 2.8 

Butter .3.8 

Milk-sugar 5.0 

Salts 7 

The  following  is  the  mode  of  preparing  the  milk  :  Allow  one-third  of  a 
pint  of  new  milk  to  stand  for  about  twelve  hours ;  remove  the  cream, 
and  add  to  it  two-thirds  of  a  pint  of  new  milk,  as  fresh  from  the  cow  as 
possible.  Into  the  one-third  of  a  pint  of  blue  milk  left  after  the 
abstraction  of  the  cream  put  a  piece  of  rennet  about  one  inch  square. 
Set  the  vessel  in  warm  water  until  the  milk'is  fully  curdled — an  opera- 
tion requiring  from  five  to  fifteen  minutes,  according  to  the  activity  of 
the  rennet,  whicli  should  be  removed  as  soon  as  the  curdling  commences 
and  put  into  an  egg-cup  for  use  on  subsequent  occasions,  as  it  may  be 
employed  daily  for  a  month  or  two.  Break  uj)  the  curd  repeatedly,  and 
carefully  se])arate  the  whole  of  the  whey,  which  should  then  be  rapidly 
heatc'd  to  boiling  in  a  small  tin  pan  ])laced  ovei'  a  s})irit  or  gas  lamp. 
During  the  heating  a  further  ([uantity  of  casein,  technically  (called  '  flcet- 
ings,'  separates,  and  must  be  removed  by  straining  through  muslin. 
Now  di.ssolve  110  grains  of  powdered  sugar  of  milk  in  the  hot  whey,  and 
mix  it  witii  the  two-thirds  of  a  ])iiit  of  new  milk  to  which  the  cream 
from  the  other  third  of  a  pint  was  added  as  already  descriljcd.  The 
'  I'Vank land's  F.xpc.rimenlai  Reaearches  in  Clieininlrj/,  p.  843. 


572 


THE  PUERPERAL  STATE. 


artificial  milk  should  be  used  within  twelve  hours  of  its  preparation, 
and  it  is  almost  needless  to  add  that  all  the  vessels  employed  in  its  manu- 
facture and  administration  should  be  kept  scrupulously  clean."  ^ 

Method  of  Hand-feeding. — Much  of  the  success  of  bottle-feeding  must 
depend  on  minute  care  and  scrupulous  cleanliness — points  which  cannot 
be  too  strongly  insisted  on.  Particular  attention  should  be  paid  to  pre- 
paring the  food  fresh  for  every  meal,  and  to  keeping  the  feeding-bottle 
and  tubes  constantly  injwater  jvlienjipj^jn  jise,  so  that  minute  particles 
of  milk  may  not  remain  about  them  and  become  sour.  A  neglect  of  this 
is  one  of  the  most  fertile  sources  of  the  thrush  from  which  bottle-fed 
infants  often  suffer.  The  particular  form  of  bottle  used  is  not  of  much 
consequence.  Those  now  commonly  employed,  with  a  long  india-rubber 
tube  attached,  are  preferable  to  the  older  forms  of  flat  bottle,  as  they 
necessitate  strong  suction  on  the  part  of  the  infant,  thus  forcing  it  to 
swallow  the  food  more  slowly.  Care  must  be  taken  to  give  the  meals 
at  stated  periods,  as  in  breast-feeding,  and  these  should  be  at  first  about 
two  hours  apart,  the  intervals  being  gradually  extended.  The  nurse 
should  be  strictly  cautioned  against  the  common  practice  of  placing  the 
bottle  beside  the  infant  in  its  cradle  and  allowing  it  to  suck  to  repletion 
— a  practice  which  leads  to  over-distension  of  the  stomach  and  conse- 
quent dyspepsia.  The  child  should  be  raised  in  the  arms  at  the  proper 
time,  have  its  food  achninistered,  and  then  be  replaced  in  the  cradle  to 
sleep.  In  the  first  few  weeks  of  bottle-feeding  constipation  is  very  com- 
mon, and  may  be  effectually  remedied  by  placing  as  much  phosphate  of 
soda  as  will  lie  on  a  threepenny-piece  in  the  bottle  two  or  three  times  in 
the  twenty-four  hours. 

Other  Kinds  of  Food. — If  this  system  succeed,  no  other  food  should 
be  given  until  the  child  is  six  or  seven  months  old,  and  then  some  of 
the  various  infant's  foods  may  be  cautiously  commenced.  Of  these 
there  are  an  immense  number  in  common  use,  some  of  which  are  good 
articles  of  diet,  others  are  unfitted  for  infants.  In  selecting  them  we 
have  to  see  that  they  contain  the  essential  elements  of  nutrition  in  proper 
combination.  All  those,  therefore,  that  are  purely  starchy  in  character, 
such  as  arrowroot,  corn  flour,  and  the  like,  should  be  avoided,  while 
those  that  contain  nitrogenous  as  well  as  starch  elements  may  be  safely 
given.  Of  the  latter  the  entire  wheat  flour,  M^hich  contains  the  husks 
ground  down  with  the  wheat,  generally  answers  admirably  ;  and  of  the 
same  character  are  rusks,  tops  and  bottoms,  Nestle's  or  Liebig's  infant's 


^  The  following  recipe  yields  the  same  results,  but  the  method  is  easier,  and  I  find 
that  nurses  prepare  the  milk  with  less  difficulty  when  it  is  followed :  "  Take  half  a 
pint  of  skimmed  milk,  heat  it  to  about  96°,  and  put  into  the  warmed  milk  a  piece  of 
rennet  about  an  inch  square.  Set  the  milk  to  stand  in  the  fender  or  over  a  lamji  imtil 
it  is  quite  warm.  When  it  is  set,  take  the  rennet  out  and  break  up  the  curd  quite 
small  with  a  knife,  and  let  it  stand  ten  or  fifteen  minutes,  when  the  curd  will  sink. 
Then  pour  the  whey  into  a  saucepan,  and  let  it  boil  cpiickly.  Measure  one-third  of  a 
pint  of  this  whey,  and  dissolve  in  it,  when  hot,  a  powder  containing-  110  grains  of  sugar 
of  milk.  When  this  third  of  a  'pini  of  whey  is  quite  cold  add  to  it  two-thirds  of  a  pint  of 
new  milk  and  two  teaspoonfuls  of  cream,  stirring  the  whole  together.  The  food  should 
be  made  fresh  every  twelve  hours,  and  warmed  as  required.  The  piece  of  rennet  when 
taken  out  can  be  kept  in  an  egg-cup  and  used  for  ten  days  or  a  fortnight." — N.  B.  It  is 
often  advisable  during  the  first  month  to  use  rather  more  than  a  thii'd  of  a  pint  of 
whey,  as  the  milk  is  apt  to  be  rather  too  rich  for  a  newly-born  child. 


PUERPERAL  ECLAMPSIA.  573 

food,  and  many  others.  If  the  child  be  pale  and  flabby,  some  more 
purely  animal  food  may  often  be  given  twice  a  day,  and  great  benefit 
may  be  derived  from  a  single  meal  of  beef,  chicken,  or  veal  tea,  with  a 
little  bread-crumb  in  it,  especially  after  the  sixth  or  seventh  month. 
Milk,  however,  should  still  form  the  main  article  of  diet,  and  should 
continue  to  do  so  for  many  months. 

Management  when  Milk  Disagrees. — If  the  child  be  pale,  flabby,  and 
do  not  gain  flesh,  more  especially  if  diarrhoea  or  other  intestinal  dis- 
turbance be  present,  we  may  be  certain  that  hand-feeding  is  not  answer- 
ing satisfactorily  and  that  some  change  is  required.  If  the  child  be  not 
too  old  and  will  still*  take  the  breast,  that  is  certainly  the  best  remedy, 
but  if  that  be  not  possible  it  is  necessary  to  alter  the  diet.  When  milk 
disagrees,  cream,  in  the  proportion  of  one  tablespoonful  to  three  of 
water,  sometimes  answers  as  well.  Occasionally  also  Liebig's  or  Mel- 
lin's  infant's  food,  when  carefully  prepared,  renders  good  service.  Too 
often,  however,  when  once  diarrhoea  or  other  intestinal  disturbance  has 
set  in,  all  our  efibrts  may  prove  unavailing,  and  the  health,  if  not  the 
life,  of  the  infant  becomes  seriously  imperilled.  It  is  not,  however, 
within  the  scope  of  this  work  to  treat  of  the  disorders  of  infants  at  the 
breast,  the  proper  consideration  of  which  requires  a  large  amount  of 
space,  and  I  therefore  refrain  from  making  any  further  remarks  on  the 
subject. 


CHAPTER   III. 

PUEEPEKAL    ECLAMPSIA. 


By  the  term  puerperal  eclamjisia  is  meant  a  peculiar  kind  of  epilepti- 
form convulsions  which  may  occur  in  the  latter  months  of  pregnancy  or 
during  or  after  parturition,  and  it  constitutes  one  of  the  most  formidable 
diseases  with  which  the  obstetrician  has  to  cope.  The  attack  is  often  so 
sudden  and  unexpected,  so  terrible  in  its  nature,  and  attended  with  such 
serious  danger  both  to  the  mother  and  child,  that  the  disease  has 
attracted  much  attention. 

Its  Doubtful  Etiology. — The  researches  of  Lever,  Braun,  Frerichs, 
and  many  other  writers  who  have  shown  the  frequent  association  of 
eclampsia  with  al})uminuria  have,  of  late  years,  been  supposed  to  clear 
up  to  a  great  extent  the  etiology  of  the  disease,  and  to  prove  its  depend- 
ence on  the  retention  of  urinary  elements  in  the  blood.  While  the  uri- 
nary origin  of  eclampsia  has  been  pn^tty  generally  accc]>ted,  more  recent 
observations  liave  tended  to  throw  doubt  on  its  essential  dependence  on 
this  cause,  so  that  it  can  hardly  be  said  that  we  arc  yet  in  a  position  to 
explain  its  true  pathology  with  certainty.  These  points  will  re(juire 
separate  discussion,  but  it  is  first  necessary  to  desci'ibe  the  character  and 
history  of  the  attack. 


574  THE  PUERPERAL  STATE. 

Considerable  confusion  exists  in  the  description  of  puerperal  convul- 
sions from  the  confounding  of  several  essentially  distinct  diseases  under 
the  same  name.  Thus,  in  most  obstetric  works  it  has  been  customary 
to  describe  three  distinct  classes  of  convulsion — the  epUeptit;  the  hyster- 
ical, and  the  apoplectic.  The  two  latter,  however,  come  under  a  totally 
different  category.  A  pregnant  ^voman  may  suffer  from  hj-stcrical  par- 
oxysms, or  she  may  be  attacked  with  apoplexy,  accompanied  ^\'ith  coma 
and  followed  by  paralysis.  But  these  conditions  in  the  pregnant  or 
parturient  woman  are  identical  with  the  same  diseases  in  the  non-preg- 
nant, and  are  in  no  way  special  in  their  nature.  True  eclampsia,  how- 
ever, is  different  in  its  clinical  history  from  epilepsy,  although  the  par- 
oxysms, while  they  last,  are  essentially  the  same  as  those  of  an  ordinary 
epileptic  fit. 

__^fmwmi^  — ^11  attack  of  eclampsia  seldom  occurs  with- 

out having  been  preceded  by  certain  more  or  less  well-marked  precur- 
sory svmptoms.  It  is  true  that  in  a  considerable  number  of  cases  these 
are  so  slight  as  not  to  attract  attention,  and  suspicion  is  not  aroused 
until  the  jmtient  is  seized  with  convulsions.  Still,  subsequent  investiga- 
tions will  very  generally  sho^A'  that  some  symptoms  did  exist,  which,  if 
observed  and  properly  interpreted,  might  have  put  the  practitioner  on 
his  guard  and  possibly  have  enabled  him  to  ward  off  the  attack.  Hence 
a  knowledge  of  them  is  of  real  practical  value.  The  most  conimon  are 
associated  with  the  cerebrum,  such  asjievere  headache,  which  is  the  one 
most  generally  observed  and  is  sometimes  limited  to  one  side  of  the  head. 
Transient  attacks_ofjiizzdnfisg,  sjjots  befoj-£-lhe_£yes,  loss^iif  sight,  or 
impairment  of  the  intellectual  faculties  are  also  not  uncommon.  These 
signs  in  a  pregnant  woman  are  of  the  gravest  import,  and  should  at 
once  call  for  investigation  into  the  nature  of  the  case.  Less  marked 
indications  sometimes  exist  in  the  form  of  jiTitabiIity.,^ightJieadache 
or  stupor,  and  a  general  feeling  of  iiidisposition.  Another  important 
premonitory  sign  is  oedema  of  the  subcutaneous  cellular  tissue,  especially 
of  the  face  or  upper  extremities,  which  should  at  once  lead  to  an  exam- 
ination of  the  urine. 

Symptoms  of  the  Attack. — Whether  such  indications  have  preceded  an 
attack  or  not,  as  soon  as  the  convulsion  comes  on  there  can  no  longer  be 
any  doubt  as  to  the  nature  of  the  case.  The  attack  is  generally  sudden 
in  its  onset,  and  in  its  character  is  precisely  that  of  a  severe  epileptic  fit 
or  of  the  convulsions  in  children.  Close  observation  shows  that  there 
is  at  first  a  short  period  of  tonic  spasm,  affecting  the  entire  muscular 
system.  This  is  almost  immediately  succeeded  by  violent  clonic  con- 
tractions, generally  commencing  in  the  muscles  of  the  face,  Avhich  twitch 
violently ;  the  expression  is  horribly  altered  ;  the  globes  of  the  eyes  are 
turned  up  under  the  eyelids,  so  as  to  leave  only  the  white  sclerotics  vis- 
ible ;  and  the  angles  of  the  mouth  are  retracted  and  fixed  in  a  convulsive 
grin.  The  tongue  is  at  the  same  time  protruded  forcibly,  and,  if  care 
be  not  taken,  is  apt  to  be  lacerated  by  the  violent  grinding  of  the  teeth. 
The  face,  at  first  pale,  soon  becomes  livid  and  cyanosed,  while  the  veins 
of  the  neck  are  distended  and  the  carotids  beat  vigorously.  Frothy 
saliva  collects  about  the  mouth,  and  the  whole  appearance  is  so  changed 
,  as  to  render  the  patient  quite  unrecognizable.     The  convulsive  move- 


PUERPERAL  ECLAMPSIA.  575 

ments  soon  attack  the  muscles  of  the  body.  The  hands  and  arms,  at 
first  rigidly  fixed,  with  thej:lnmibs^?lench(^^  begin  to 

jerk,  and  the  whole  muscular  system  is  thrown  into  rapidly-recurring 
convulsive  sjsasms.  It  is  evident  that  the  involuntary  muscles  are  im- 
plicated in  tll^e  convulsive  action,  as  well  as  the  voluntary.  This  is 
shown  by  a  temporary  arrest  of  respiration  at  the  commencement  of  the 
attack,  followed  by  irregular  and  hurried  respiratory  movements,  pro- 
ducing a  peculiar  hissing  sound.  The  occasional  involuntary  expulsion 
of  urine  and  feces  indicates  the  same  fact.  During  the  attack  the  patient 
is  absolutely  unconscious,  sensibility  is  totally  suspended,  and  she  has 
afterward  no  recollection  of  what  has  taken  place.  Fortunately,  the 
convulsion  is  not  of  long  duration,  and  at  the  outside  does  not  last  more 
than  three  or  four  minutes,  generally  not  so  long.  In  most  cases,  after 
an  interval  there  is  a  recurrence  of  the  convulsion,  characterized  by  the 
same  phenomena,  and  the  paroxysms  are  repeated  with  more  or  less  force 
and  frequency  according  to  the  severity  of  the  attack.  Sometimes  sev- 
eral hours  may  elapse  before  a  second  convulsion  comes  on ;  at  others 
the  attacks  may  recur  very  often,  with  only  a  few  minutes  between  them. 
In  the  slighter  forms  of  eclampsia  there  may  not  be  more  than  two  or 
three  paroxysms  in  all ;  in  the  more  serious  as  many  as  fifty  or  sixty 
have  been  recorded. 

Condition  between  the  Attacks. — After  the  first  attack  the  patient  gen- 
erally soon  recovers  her  consciousness,  being  somewhat  dazed  and  som- 
nolent, with  no  clear  conception  of  what  has  occurred.  If  the  parox-J 
ysms  be  frequently  repeated,  more  or  less  profound  coma  continues  in 
the  intervals  between  them  ;  which  no  doubt  depends  upon  intense  cere- 
bral congestion,  resulting  from  the  interference  with  the  circulation  in 
the  great  veins  of  the  neck,  produced  by  spasmodic  contraction  of  the 
muscles.  The  coma  is  rarely  complete,  the  patient  showing  signs  of 
sensibility  when  irritated,  and  groaning  during  the  uterine  contractions.  ■ 
In  the  worst  class  of  cases  the  torpor  may  become  intense  and  continu- 
ous, and  in  this  state  the  patient  may  die.  When  the  convulsions  have 
entirely  stopped  and  the  patient  has  completely  regained  her  conscious- 
ness, and  is  apparently  convalescent,  recollection  of  what  has  taken 
place  during  and  some  time  before  the  attack  may  be  entirely  lost ;  and 
this  condition  may  last  for  a  considerable  time.  A  curious  instance  of 
this  once  came  under  my  notice  in  a  lady  who  had  lost  her  brother,  to 
whom  she  was  greatly  attached,  in  the  week  immediately  preceding  her 
confinement,  and  in  whom  the  mental  distress  seemed  to  have  had  a  good 
deal  to  do  in  determining  the  attack.  It  was  many  weeks  before  she 
recovered  her  memory,  and  during  that  time  she  recollected  nothing 
about  the  circumstances  connected  ^itli  her  brother's  death,  the  whole 
of  tliat  week  beinp;  as  it  were  blotted  out  of  her  recollection. 

Relation  of  the  Attacks  to  La/tor. — If  the  convulsions  come  on  during 
})regnancy,  we  may  look  upon  the  advent  of  labor  as  almost  a  certainty ; 
and  if  we  consider  the  severe  nervous  shock  and  general  disturbance, 
this  is  the  result  we  might  reasona])ly  anti(!i])ate.  If  they  occur,  as  is 
not  uncommon,  for  the  first  tiiix;  during  labor,  tlie  pains  gen(!rally  con- 
tinue witli  increased  force  and  fr('(|ii('ncy,  since  the  uterus  j)artakcs  of 
the  convulsive  action.     It  has  not  rarely  li;i|i|)('ned  that  the  pains  have 


576  THE  PUERPERAL  STATE. 

gone  on  with  such  intensity  that  the  child  has  been  born  quite  unex- 
pectedly, the  attention  of  the  practitioner  being  taken  up  with  the  pa- 
tient. In  many  cases  the  advent  of  fresh  paroxysms  is  associated  with 
the  commencement  of  a  pain,  the  irritation  of  which  seems  sutHcient  to 
bring  on  the  convulsion. 

Results  to  the  Ilothei^  and  Child. — The  results  of  eclampsia  vary 
according  to  the  severity  of  the  paroxysms.  It  is  generally  said  that 
about  1  in  3  or  4  cases  dies.  The  mortality  has  certainly  lessened  of 
late  years,  probably  in  consequence  of  improved  knowledge  of  the 
nature  of  the  disease  and  more  rational  modes  of  treatment.  This  is 
well  shown  by  Barker,^  who  found  in  1855  a  mortality  of  32  per  cent, 
in  cases  occurring  before  and  during  labor,  and  22  per  cent,  in  those 
after  labor,  while  since  that  date  the  mortality  has  fallen  to  14  per  cent. 
The  same  conclusion  is  arrived  at  by  Dr.  Phillips,^  who  has  shown  that 
the  mortality  has  greatly  lessened  since  the  practice  of  repeated  and  in- 
discriminate bleeding,  long  considered  the  sheet-anchor  in  the  disease, 
has  been  discontinued  and  the  administration  of  chloroform  substituted. 
1'  Cause  of  Death. — Death  may  occur  during  the  paroxysm,  and  then  it 
I  may  be  due  to  the  long  continuance  of  the  tonic  spasm  producing  as- 

r(v^v.^    I  phyxia.     It  is  certain  that  as  long  as  the  tonic  spasm  lasts  the  respira- 
'"tion  is  suspended,  just  as  in  the  convulsive  disease  of  children  known  as 
laryngismus  stridulus ;  and  it  is  possible  also  that  the  heart  may  share 
in  the  convulsive  contraction  which  is  known  to  affect  other  involuntary 
muscles.     More  frequently  death  happens  at  a  later  period,  from  the 

^^y^^^^^Z^}  combined  effects  of  exhaustion  and  asphyxia.  The  records  of  post-mor- 
"  tem  examinations  are  not  numerous ;  in  those  we  possess  the  principal 
changes  have  been  an  anaemic  condition  of  the  brain,  w^ith  some  oedema- 
tous  infiltration.  In  a  few  rare  cases  the  convulsions  have  resulted  in 
effusion  of  blood  into  the  ventricles  or  at  the  base  of  the  brain.  The 
prognosis  as  regards  the  child  is  also  serious.  Out  of  36  children.  Hall 
Davis  found  26  born  alive,  10  being  stillborn.  There  is  good  reason  to 
believe  that  the  convulsion  may  attack  the  child  in  uiero — of  this  several 
examples  are  mentioned  by  Cazeaux — or  it  may  be  subsequently  attacked 
with  convulsions,  even  when  apparently  healthy  at  birth. 

Pathology  of  the  Disease. — The  precise  pathology  of  eclampsia  cannot 
be  considered  by  any  means  satisfactorily  settled.  When,  in  the  year 
1843,  Lever  first  showed  that  the  urine  in  patients  suffering  from  puer- 
peral convulsions  M^as  generally  highly  charged  with  albumen — a  fact 
which  subsequent  experience  has  amply  confirmed — it  Mas  thought  that 
a  key  to  the  etiology  of  the  disease  had  been  found.  It  was  known  that 
chronic  forms  of  Bright's  disease  were  frequently  associated  with  reten- 
tion of  urinary  elements  in  the  blood  and  not  rarely  accompanied  by 
convulsions.  The  natural  inference  was  drawn  that  the  convulsions  of 
eclampsia  were  also  due  to  toxaemia  resulting  from  the  retention  of  urea 
in  the  blood,  just  as  in  the  uraemia  of  chronic  Bright's  disease ;  and  this 
view  Avas  adopted  and  supported  by  the  authority  of  Braun,  Frerichs, 
and  many  other  writers  of  eminence,  and  was  generally  received  as  a 
satisfactory  explanation  of  the  facts.  Frerichs  modified  it  so  far  that 
he  held  that  the  true  toxic  element  was  not  urea  as  such,  but  carbonate 

^  The  Puerperal  Diseases,  p.  125.  ^  Guy\s  Hospital  Reports,  1870. 


^^^^^^A^tXA-tAX- 


PUERPERAL  ECLAMPSIA.  577 

of  ammonia,  resulting  from  its  decomposition,  and  experiments  were 
made  to  prove  that  the  injection  of  this  substance  into  the  veins  of  the 
lower  animals  produced  convulsions  of  precisely  the  same  character  as 
eclampsia.  Dr.  Hammond  ^  of  Marylancl  subsequently  made  a  series  of 
counter-experiments,  which  w^ere  held  as  proving  that  there  was  no  rea- 
son to  believe  that  urea  ever  did  become  decomposed  in  the  blood  in 
the  way  that  Frerichs  supposed,  or  that  the  symptoms  of  uraemia  were 
ever  produced  in  this  way.  Others  have  believed  that  the  poisonous 
elements  retained  in  the  blood  are  not  urea  or  the  products  of  its  decom- 
position, but  other  extractive  matters  which  have  escaped  detection.  As 
time  elapsed,  evidence  accumulated  to  show  that  the  relation  between 
albuminuria  and  eclampsia  was  not  so  universal  as  was  supposed,  or  at 
least  that  some  other  factors  were  necessary  to  explain  many  of  the 
cases.  jSTumerous  cases  were  observed  in  which  albumen  was  detected 
in  large  quantities,  without  any  convulsion  following,  and  that  not  only 
in  women  who  had  been  the  subject  of  Bright's  disease  before  concep- 
tion, but  also  when  the  albuminuria  was  known  to  have  developed  dur- 
ing pregnancy.  Thus,  Imbert  Goubeyre  found  that,  out  of  164  cases 
of  the  latter  kind,  95  had  no  eclampsia,  and  Blot,  out  of  41  cases,  found 
that  34  were  delivered  without  untoward  symptoms.  It  may  be  taken 
as  proved,  therefore,  that  albuminuria  is  by  no  means  necessarily  accom- 
panied by  eclampsia.  Cases  were  also  observed  in  which  the  albumen 
only  appeared  after  the  convulsion,  and  in  these  it  was  evident  that  the 
retention  of  urinary  elements  could  not  have  been  the  cause  of  the 
attack  ;  and  it  is  highly  probable  that  in  them  the  albuminuria  was  pro- 
duced by  the  same  cause  wiiich  induced  the  convulsion.  Special  atten- 
tion has  been  called  to  this  class  of  cases  by  Braxton  Hicks,^  who  has 
recorded  a  considerable  number  of  them.  He  says  that  the  nearly  simul- 
taneous appearance  of  albuminuria  and  convulsion — and  it  is  admitted 
that  the  two  are  almost  invariably  combined — must  then  be  explained 
in  one  of  three  ways : 

1st.  That  the  convulsions  are  the  cause  of  the  nephritis. 

2dly.  That  the  convulsions  and  the  nephritis  are  produced  by  the 
same  cause — e.  g,  some  detrimental  ingredient  circulating  in  the  blood, 
irritating  both  the  cerebro-spinal  system  and  other  organs  at  the  same 
time. 

3d]y.  That  the  highly-congested  state  of  the  venous  system,  induced 
by  the  spasm  of  the  glottis  in  eclampsia,  is  able  to  produce  the  kidney 
complication. 

Theoi't/  of  Traube  and  Rosenstein. — More  recently,  Tralibe  and  Rosen- 
stein  have  advanced  a  theory  of  eclampsia  purporting  to  explain  these 
anomalies.  They  refer  the  occurrence  of  eclampsia  to  acute  cerebral 
anajmia  rcsidting  from  changes  in  the  blood  incident  to  pregnancy.  The 
primary  fac^tor  is  the  hydrsemic  condition  of  the  blood  which  is  an  ordin- 
ary con(;omitant  of  the  pregnant  state,  and  of  course  when  there  is  also 
alburaimiria  the  watery  condition  of  the  blood  is  greatly  intensified ; 
hence  the  fn^quent  association  of  the  two  states.  Accom])anyiug  this 
condition  of  the  blood  there  is  increased  tension  of  the  arterial  system, 
wliicli  is  favored  by  the  hypertrophy  of  the  heart  which  is  known  to  be 

'  Aiiicr.  Journ.,  18f!].  ^  Obski.  'J'rans.,vo\.  viii. 

37 


578  THE  PUERPERAL  STATE. 

a  normal  occurrence  in  pregnancy.  The  result  of  these  combined  states 
is  a  temporary  hyperseniia  of  the  brain,  which  is  rapidly  succeeded  by 
serous  effusion  into  the  cerebral  tissues,  resulting  in  pressure  on  its  mi- 
nute vessels  and  consequent  anaemia.  There  is  much  in  this  theory  that 
accords  with  the  most  recent  vieMS  as  to  the  etiology  of  convulsive  dis- 
ease ;  as,  for  example,  the  researches  of  Kussmaul  and  Tenner,  who  had 
experimentally  proved  the  dependence  of  convulsion  on  cerebral  anaemia, 
and  of  Brown-Sequard,  who  showed  that  an  anaemic  condition  of  the 
nerve-centres  preceded  an  epileptic  attack.  It  explains  also  very  satis- 
factorily how  the  occurrence  of  labor  should  intensify  the  convulsions, 
since  during  the  acme  of  the  pains  the  tension  of  the  cerebral  arterial 
system  is  necessarily  greatly  increased.  There  are,  however,  obvious 
difficulties  against  its  general  acceptance.  For  example,  it  does  not 
satisfactorily  account  for  those  cases  which  are  preceded  by  well-marked 
precursory  symptoms,  and  in  which  an  abundance  of  albumen  is  present 
in  the  urine.  Here  the  premonitory  signs  are  precisely  those  which 
precede  the  development  of  uraemia  in  chronic  Bright's  disease,  the 
dependence  of  which  on  the  retention  in  the  blood  of  urinary  elements 
can  hardly  be  doubted.  Moreover,  it  has  been  shown  by  Ldhlein  and 
others  that  on  post-mortem  examination  the  brain  does  not,  as  a  rule, 
exhibit  the  oedema,  anaemia,  and  flattened  convolutions  which  this  theory 
assumes. 

Views  of  MacDonald. — MacDonald^  has  published  an  interesting 
paper  on  this  subject,  in  which  he  describes  two  very  careful  post-mortem 
examinations.  In  these  he  found  extreme  anaemia  of  the  cerebro-spinal 
centres,  with  congestion  of  the  meninges,  but  no  evidence  of  oedema. 
He  inclines  to  the  belief  that  eclampsia  is  caused  by  irritation  of  the 
vaso-motor  centre  in  consequence  of  an  anaemic  condition  of  the  blood 
produced  by  the  retention  in  it  of  excrementitious  matters  which  the 
kidneys  ought  to  have  removed,  this  over-stimulation  resulting  in 
anaemia  of  the  deeper-seated  nerve-centres  and  consequent  convulsion. 

Excitability  of  Nervous  System. — This  key  to  the  liability  of  the  puer- 
peral woman  to  convulsive  attacks  is  no  doubt  to  be  found  in  the  pecu- 
liar excitable  condition  of  the  nervous  system  in.  pregnancy — a  fact 
which  was  clearly  pointed  out  by  the  late  Dr.  Tyler  Smith  and  by  many 
other  writers.  Her  nervous  system  is  in  this  respect  not  unlike  that  of 
children,  in  whom  the  predominant  influence  and  great  excitability  of 
the  nervous  system  are  well-established  facts,  and  in  whom  precisely 
similar  convulsive  seizures  are  of  common  occurrence  on  the  application 
of  a  sufficiently  exciting  cause. 

Exciting  Causes. — Admitting  this,  we  require  some  cause  to  set  the 
predisposed  nervous  system  into  morbid  action ;  and  this  we  may  have 
either  in  a  toxaemic  or  in  an  extremely  watery  condition  of  the  blood, 
associated  with  albuminuria ;  or  along  with  these,  or  sometimes  inde- 
pendently of  them,  in  some  excitement,  such  as  strong  emotional  disturb- 
ance. It  is  highly  probable,  however,  that  extreme  anaemia  is  one  of 
the  actual  conditions  of  the  nerve-centres — a  fact  of  much  practical 
importance  in  reference  to  treatment. 

^  See  his  volume  of  collected  essavs  entitled  Heart  Disease  during  Pregnanaj,  London, 
1878. 


PUERPERAL  ECLAMPSIA.  579 

Treatment. — The  management  of  cases  in  which  tlie  occurrence  of  sus- 
picious symptoms  has  led  to  the  detection  of  albuminuria,  has  already 
been  fully  discussed  (p.  209).  We  shall  therefore  here  only  consider  the 
treatment  of  cases  in  which  convulsions  have  actually  occurred. 

Venesection. — Until  quite  recently  venesection  was  regarded  as  the 
sheet-anchor  in  the  treatment,  and  blood  was  always  removed  copiously, 
and,  there  is  sufficient  reason  to  believe,  with  occasional  remarkable  bene- 
fit. Many  cases  are  recorded  in  which  a  patient  in  apparently  profound 
coma  rapidly  regained  her  consciousness  when  blood  was  extracted  in 
sufficient  quantity.  The  improvement,  howev^er,  was  often  transient, 
the  convulsions  subsequently  recurring  with  increased  vigor.  There  are 
good  theoretical  grounds  for  believing  that  bloodletting  can  only  be  of 
merely  temporary  use,  and  may  even  increase  the  tendency  to  convulsion. 
These  are  so  well  put  by  Schroeder  that  I  cannot  do  better  than  quote 
his  observations  on  this  point.  "  If,"  he  says,  "  the  theory  of  Tralibe 
and  Rosenstein  be  correct,  a  sudden  depletion  of  the  vascular  system, 
by  which  the  pressure  is  diminished,  must  stop  the  attacks.  From 
experience  it  is  known  that  after  venesection  the  quantity  of  blood  soon 
becomes  the  same  through  the  serum  taken  frojn  all  the  tissues,  while 
the  quality  is  greatly  deteriorated  by  the  abstraction  of  blood.  A  short 
.time  after  venesection  we  shall  expect  to  find  the  former  blood-pressure 
in  the  arterial  system,  but  the  blood  far  more  watery  than  previously. 
From  this  theoretical  consideration  it  follows  that  abstraction  of  blood, 
if  the  above-mentioned  conditions  really  cause  convulsions,  must  be 
attended  by  an  immediate  favorable  result,  and  under  certain  circum- 
stances the  whole  disease  may  surely  be  cut  short  by  it.  But  if  all  other 
conditions  remain  the  same  the  blood-pressure  will  after  some  time  again 
reach  its  former  height.  The  quality  of  blood  has  in  the  mean  time  been 
greatly  deteriorated,  and  consequently  the  danger  of  the  disease  will  be 
increased." 

These  views  sufficiently  well  explain  the  varying  opinions  held  with 
regard  to  this  remedy,  and  enable  us  to  understand  why,  while  the 
effects  of  venesection  have  been  so  lauded  by  certain  authors,  the  mor- 
tality has  admittedly  been  much  lessened  since  its  indiscriminate  use  has 
been  abandoned.  It  does  not  follow  because  a  remedy,  when  carried  to 
exee<H,  is  apt  to  be  hurtful,  that  it  should  be  discarded  altogether;  and 
I  have  no  doubt  tliat  in  properly-selected  cases  and  judiciously  employed, 
venesection  is  a  valuable  aid  in  the  treatment  of  eclampsia,  and  that  it  is 
specially  likely  to  be  useful  in  mitigating  the  first  violence  of  the  attack 
and  in  giving  time  for  other  remedies  to  come  into  action.  Care  should, 
how(!vcr,  be  taken  to  select  the  cases  properly,  and  it  will  be  specially 
indicated  when  there  is  marked  evidence  of  great  cerebral  congestion 
and  vascular  tension,  such  as  a  livid  face,  a  full  bounding  pulse,  and 
strong  pulsation  in  the  carotids.  The  general  constitution  of  the  j)atient 
may  alsf)  serve  as  a  guide  in  detennining  its  use,  and  we  shall  be  the 
more  disj)osed  to  resort  to  it  if  the  patient  be  a  strong  and  healthy  woman  ; 
while,  on  the  other  hand,  if  she  be  feeble  and  weak,  we  may  wisely  dis- 
card it  and  trust  entirely  to  other  means.  In  any  case,  it  must  be  looked 
npon  as  a  temporary  expcflicnt  only,  useful  in  warding  off  innnediate 
danger  to  the  cerebral  tissues,  but  never  as  the  main  agent  in  treatment. 


580  THE  PUERPERAL  STATE. 

Nor  can  it  be  permissible  to  bleed  in  the  heroic  manner  frequently  recom- 
mended. A  single  bleeding,  the  amount  regulated  by  the  effect  produced, 
is  all  that  is  ever  likely  to  be  of  service. 

[After  the  discovery  of  the  urseraic  origin  of  eclampsia  in  pregnant 
women  the  treatment  by  bleeding  was  very  generally  abandoned  in  the 
United  States ;  but  the  more  recent  investigations  of  the  causes  of  death 
have  produced  a  reconsideration  of  this  plan  of  treatment,  and  the  tend- 
ency of  the  profession  during  the  last  ten  or  fifteen  years  has  been  toward 
venesection  as  a  preventive  of  cerebral  complications.  In  primiparse 
with  a  full  pulse  and  flushed  face  the  rule  with  many  of  our  obstetrical 
practitioners  is  to  bleed  the  patient  as  early  as  practicable,  and  to  do  this 
at  least  once  effectually,  so  as  to  produce,  if  possible,  a  noticeable  impres- 
sion. Where  there  are  positive  evidences  of  the  existence  of  Bright's 
disease,  of  course  tliis  is  inadniissible. — Ed.] 

Compression  of  the  Carotids. — As  a  temporary  expedient,  having  the 
same  object  in  view,  compression  of  the  carotids  during  the  paroxysms 
is  M'orthy  of  trial.  This  was  proposed  by  Trousseau  in  the  eclampsia 
of  infants,  and  in  the  single  case  of  eclampsia  in  which  I  have  tried  it 
seemed  to  be  decidedly  beneficial.  It  is  a  simple  measure,  and  it  offers 
the  advantage  of  not  leading  to  any  permanent  deterioration  of  the  blood, 
as  in  venesection. 

Administration  of  Purgatives. — As  a  subsidiary  means  of  diminishing 
vascular  tension  the  administration  of  a  strong  purgative  is  desirable, 
and  has  the  further  effect  of  removing  any  irritant  matter  that  may  be 
lodged  in  the  intestinal  tract.  If  the  patient  be  conscious,  a  full  dose  of 
the  compound  jalap  powder  may  be  given,  or  a  few  grains  of  calomel 
combined  with  jalap ;  and  if  she  be  comatose  and  unable  to  swallow,  a 
drop  of  croton  oil  or  a  quarter  of  a  grain  of  elaterium  may  be  placed  on 
the  back  of  the  tongue. 

Administration  of  Sedatives  and  Narcotics. — The  great  indication  in 
the  management  of  eclampsia  is  the  controlling  of  convulsive  action  by 
means  of  sedatives.  Foremost  amongst  them  must  be  placed  the  inha- 
lation of  chloroform — a  remedy  wdiicli  is  frequently  remarkably  useful, 
and  which  has  the  advantage  of  being  applicable  at  all  stages  of  the  dis- 
ease and  whether  the  patient  be  comatose  or  not.  Theoretical  objections 
have  been  raised  against  its  employment,  as  being  likely  to  increase 
cerebral  congestion  :  of  this  there  is  no  satisfactory  proof ;  on  the  con- 
trary, there  is  reason  to  think  that  chloroform  inhalation  has  rather  the 
effect  of  lessening  arterial  tension,  while  it  certainly  controls  the  violent 
muscular  action  by  which  the  hypersemia  is  so  much  increased.  Practi- 
cally, no  one  who  has  used  it  can  doubt  its  great  value  in  diminishing 
the  force  and  frequency  of  the  convulsive  paroxysms.  Statistically,  its 
usefulness  is  shown  by  Charpentier  in  his  thesis  on  the  effects  of  various 
methods  of  treatment  in  eclampsia,  since,  out  of  63  cases  in  which  it 
was  used,  in  48  it  had  the  efiFect  of  diminishing  or  arresting  the  attacks, 
1  only  proving  fatal.  The  mode  of  administration  has  varied.  Some 
have  given  it  almost  continuously,  keeping  the  patient  in  a  more  or  less 
profound  state  of  anesthesia.  Others  have  contented  themselves  with 
carefully  Avatching  the  patient,  and  exhibiting  the  chloroform  as  soon  as 
there  w^ere  any  indications  of  a  recurring  paroxysm,  with  the  yiew  of 


PUERPERAL   ECLAMPSIA.  581 

controlling  its  intensity.  The  latter  is  the  plan  I  have  myself  adojDted, 
and  of  the  value  of  which  in  most  cases  I  have  no  doubt.  Every  now 
and  again  cases  will  occur  in  which  chloroform  inhalation  is  insufficient 
to  control  the  paroxysm,  or  in  which,  from  the  very  cyanosed  state  of 
the  patient,  its  administration  seems  contraindicated.  Moreover,  it  is 
advisable  to  have,  if  possible,  some  remedy  more  continuous  in  its  action 
and  requiring  less  constant  personal  supervision.  Latterly,  the  internal 
administration  of  chloral  has  been  recommended  for  this  purpose.  My 
own  experience  is  decidedly  in  its  favor,  and  I  have  used,  as  I  believe, 
with  marked  advantage  a  combination  of  chloral  with  bromide  of  potas- 
sium, in  the  proportion  of  twenty  grains  of  the  former  to  half  a  drachm 
of  the  latter,  repeated  at  intervals  of  from  four  to  six  hours.  If  the 
patient  be  unable  to  swallow,  the  chloral  may  be  given  in  an  enema  or 
hypodermically,  six  grains  being  diluted  in  3j  of  water  and  injected 
under  the  skin.  The  remarkable  influence  of  bromide  of  potassium  in 
controlling  the  eclampsia  of  infants  would  seem  to  be  an  indication  for 
its  use  in  puerperal  cases.  Fordyce  Barker  is  opposed  to  the  use  of 
chloral,  which  he  thinks  excites  instead  of  lessens  reflex  irritability.^ 
Another  remedy,  not  entirely  free  from  theoretical  objections,  but  strongly 
recommended,  is  the  subcutaneous  injection  of  morphia,  which  has  the 
advantage  of  being  applicable  when  the  patient  is  quite  unable  to  swal^, 
low.  It  may  be  given  in  doses  of  one-third  of  a  grain,  repeated  in  a 
few  hours,  so  as  to  keep  the  patient  well  under  its  influence.  It  is  to  be 
remembered  that  the  object  is  to  control  muscular  action,  so  as  to  pre- 
vent as  much  as  possible  the  violent  convulsive  paroxysm,  and  therefore 
it  is  necessary  that  the  narcosis,  however  produced,  should  be  continuous. 
It  is  rational,  therefore,  to  combine  the  intermittent  action  of  chloi'oform 
with  the  more  continuous  action  of  other  remedies,  so  that  the  former 
should  supplement  the  latter  when  insufficient.  Inhalation  of  the  nitrite 
of  amyl  has  been  recommended  on  physiological  grounds  as  likely  to  be 
useful,  and  is  well  worthy  of  trial,  bat  of  its  action  I  have  as  yet  no 
personal  experience.  Pilocarpine  has  recently  been  tried  in  the  hope 
that  the  diaphoresis  and  salivation  it  produces  might  diminish  arterial 
tension  and  free  the  blood  of  toxic  matters.  Braun^  administered  3 
centigrammes  of  the  muriate  of  pilocarpine  hypodermically,  and  reports 
favorably  of  the  result ;  Fordyce  Barker,''*  however,  is  of  opinion  that 
it  produces  so  much  depression  as  to  be  dangerous. 

Other  remedies,  supposed  to  act  in  the  way  of  antidotes  to  urremic 
poisoning,  have  been  advised,  such  as  acetic  or  benzoic  acid,  but  they  are 
far  too  uncertain  to  have  any  reliance  placed  on  them,  and  they  distract 
attention  from  more  useful  measures. 

Precautions  during  the  Paroxysm. — Precautions  are  necessary  during 
the  fits  to  prevent  the  patient  injuring  herself,  especially  to  obviate  lace- 
ration of  the  tongue ;  the  latter  can  be  best  done  by  placing  something 
between  tlie  teeth  as  the  paroxvsm  conies  on,  such  as  the  handk;  of  a 
teaspf)on  envcilojK'd   in  several   folds  of  flannel. 

Ohsfdric  Mariar/emnit. — The  obstetric  management  of  eclam])sia  will 
naturally  give  rise  to  nnich  anxiety,  and  on  this  j)oint  there  has  been 

'  The  Puerperal  DiseuHPK,  ]).  120.  ^  Berlin  kiln.  Woch.,  June  IG,  1879. 

^^'ew  York  Med.  Rec.,  Marcli  1,  1879. 


582  THE  PUERPERAL  STATE. 

considerable  difference  of  opinion.  On  the  one  hand,  we  have  prac- 
titioners who  advise  the  immediate  emptying  of  the  uterus,  even  when 
labor  has  commenced  ;  on  the  other,  those  who  would  leave  the  labor 
entirely  alone.  Thus  Gooch  said,  "  Attend  to  the  convulsions  and  leave 
the  labor  to  take  care  of  itself;"  and  Schroeder  says,  "Especially  no 
kind  of  obstetric  manipulation  is  required  for  the  safety  of  the  mother ;" 
but  he  admits,  however,  that  it  is  sometimes  advisable  to  hasten  the 
labor  to  ensure  the  safety  of  the  child. 

In  cases  in  which  the  convulsions  come  on  during  labor  the  pains  are 
often  strong  and  regular,  the  labor  progresses  satisfactorily,  and  no  inter- 
ference is  needful.  In  others  we  cannot  but  feel  that  emptying  the  uterus 
would  be  decidedly  beneficial.  We  have  to  reflect,  however,  that  any 
active  interference  might  of  itself  prove  very  irritating  and  excite  fresh 
attacks.  The  influence  of  uterine  irritation  is  apparent  by  the  frequency 
with  which  the  paroxysms  recur  with  the  pains.  If,  therefore,  the  os  be 
undilated  and  labor  have  not  begun,  no  active  means  to  induce  it  should 
be  adopted,  although  the  membranes  may  be  ruptured  with  advantage, 
since  that  procedure  produces  no  irritation.  Forcible  dilatation  of  the 
OS,  and  especially  turning,  are  strongly  contraindicated. 

The  rule  laid  down  by  Tyler  Smith  seems  that  which  is  most  advis- 
able to  folloM^ — that  we  should  adopt  the  course  which  seems  least  likely 
t)  prove  a  source  of  irritation  to  the  mother.  Thus,  if  the  fits  seem 
evidently  induced  and  kept  up  by  the  pressure  of  the  foetus,  and  the 
head  be  within  reach,  the  forceps,  or  even  craniotomy,  may  be  resorted 
to.  But  if,  on  the  other  hand,  there  be  reason  to  think  that  the  ope- 
ration necessary  to  complete  delivery  is  likely  -per  se  to  prove  a  greater 
source  of  irritation  than  leaving  the  case  to  nature,  then  we  should  not 
interfere,  , 

d^^   *M^   i-—     )r<^'^"  -^    /l-s-i^-^vc^    AJ^      S^-i-^ 


CHAPTER  lY. 

PUEKPEEAL   INSANITY. 

Classification. — Under  the  head  of  "■Puerperal  Mania"  writers  on 
obstetrics  have  indiscriminately  classed  all  cases  of  mental  disease  con- 
nected with  pregnancy  and  parturition.  The  result  has  been  unfor- 
tunate, for  the  distinction  between  the  various  types  of  mental  disorder 
has,  in  consequence,  been  very  generally  lost  sight  of.  But  little  study 
of  the  subject  suffices  to  show  that  the  term  ''puerperal  mania"  is  wrong 
in  more  ways  than  one,  for  we  find  that  a  large  number  of  cases  are  not 
cases  of  "  mania"  at  all,  but  of  melancholia  ;  while  a  considerable  num- 
ber are  not,  strictly  speaking,  "  puerperal,"  as  they  either  come  on  dur- 
ing pregnancy  or  long  after  the  immediate  risks  of  the  puerperal  period 
are  over,  being  in  the  latter  case  associated  with  ansemia  produced  by 
over-lactation.  For  the  sake  of  brevity  the  generic  term  "  Puerperal 
Insanity"  may  be  employed  to  cover  all  cases  of  mental  disorders  con- 


PUERPERAL  INSANITY.  583 

nected  with  gestation,  which  may  be  further  conveniently  subdivided 
into  three  classes,  each  having  its  special  characteristics — viz. : 

I.  The  Insanity  of  Pregnancy. 

II.  Puerperal  Insanity,  properly  so  called — that  is,  insanity  coming 
on  within  a  limited  period  after  delivery. 

III.  The  Insanity  of  Lactation. 

This  division  is  a  strictly  natural  one,  and  includes  all  the  cases  likely 
to  come  under  observation.  The  relative  proportion  these  classes  bear 
to  each  other  can  only  be  determined  by  accurate  statistical  observations 
on  a  large  scale,  but  these  materials  we  do  not  possess.  The  returns 
from  large  asylums  are  obviously  open  to  objection,  for  only  the  worst 
and  most  confirmed  cases  find  their  way  into  these  institutions,  while  by 
far  the  greater  proportion,  both  before  and  after  labor,  are  treated  in 
their  own  homes. 

Projwrtion  of  these  Forms  of  Insanity. — Taking  such  returns  as  only 
approximate,  we  find  from  Dr.  Batty  Tuke^  that  in  the  Edinburgh 
Asylum,  out  of  155  cases  of  puerperal  insanity,  28  occurred  before 
delivery,  73  during  the  puerperal  period,  and  54  during  lactation.  The 
relative  proportions  of  each  per  hundred  are  as  follows  : 

Insanity  of  Pregnancy,  18.06  per  cent. 

Puerperal  Insanity,         47.09       " 

Insanity  of  Lactation,  34.83  " 
Marc6^  collects  together  several  series  of  cases  from  various  authorities, 
amounting  to  310  in  all,  and  the  results  are  not  very  different  from 
those  of  the  Edinburgh  Asylum,  except  in  the  relatively  smaller  num- 
ber of  cases  occurring  before  delivery.  The  percentage  is  calculated 
from  his  figures : 

Insanity  of  Pregnancy,  8.06  per  cent. 

Puerperal  Insanity,       58.06       " 

Insanity  of  Lactation,  30.30       " 
As  each  of  these  classes  differs  in  various  important  respects  from  the 
others,  it  will  be  better  to  consider  each  separately. 

Insanity  of  Pregnancy. — The  insanity  of  pregnancy  is,  without 
doubt,  the  least  common  of  the  three  forms.  The  intense  mental  de- 
pression which  in  many  women  accompanies  pregnancy,  and  causes  the~ 
patient  to  take  a  desponding  view  of  her  condition  and  to  look  forward 
to  the  result  of  her  labor  with  the  most  gloomy  apprehension,  seems  to 
be  often  only  a  lesser  degree  of  the  actual  mental  derangement  which  is 
occasionally  met  with.  The  relation  between  the  two  states  is  further 
borne  out  by  the  fact  that  a  large  majority  of  cases  of  insanity  during 
])regnancy  are  well-marked  types  of  melancholia :  out  of  28  cases  re- 
pfjrted  by  Tuke,  15  were  examples  of  pure  melaiicholia,  5  of  dementia 
witli  melancholia.  In  many  of  these  the  attack  could  l)c  traced  as  de- 
vcloj)ing  itself  out  of  the  ordinary  hy])ocliondriasis  of  ])regnau('y.  In 
others  the  symptoms  (;ame  on  at  a  later  ])eriod  of  pregnancy,  the  earlier 
months  of  which  had  not  been  marked  by  any  unusual  lowness  of 
spirits.  Tiie  age  of  tiie  j)atient  seems  to  have  some  influence,  the  pro- 
portion of  crises  between  30  and  40  years  of  age  being  much  larger  than 
in  younger  women.     A  larger  pro})ortion  of  cases  occur  in  j)rinn*j)ar{e 

'  I'din.  Med.  Journ.,  vol.  x.  '^  Traile  de  la  Folic  den  Faiiinen  encelrUes. 


584  THE  PUERPERAL  STATE. 

tlian  in  multiparse — a  fact  that  no  doubt  depends  on  the  greater  dread 
and  ajDprehension  experienced  by  >vomen  who  are  pregnant  for  the  first 
time,  especially  if  not  very  young.  Hereditary  disposition  plays  an  im- 
portant part,  as  in  all  forms  of  puerperal  insanity.  It  is  not  always  easy 
to  ascertain  the  fact  of  an  hereditary  taint,  since  it  is  often  studiously  con- 
cealed by  the  friends.  Tuke,  however,  found  distinct  evidence  of  it  in 
no  less  than  12  out  of  28  cases.  Fiirstner^  believes  that  other  neuroses 
have  an  important  influence  in  the  causation  of  the  disease.  Out  of  32 
cases  he  found  direct  hereditary  taint  in  9,  but  in  11  more  there  was  a 
family  history  of  epilepsy,  drunkenness,  or  hysteria. 

Period  of  Pregnancy  at  tvhich  it  Occurs. — The  period  of  pregnancy  at 
which  mental  derangement  most  commonly  shows  itself  varies.  JNIost 
generally,  perhaps,  it  is  at  tlie^iKLofjhejhir^^  the 

fourth  month.  It  may,  however,  begin  with  conception,  and  even  return 
with  every  impregnation.  Montgomery  relates  an  instance  in  which  it 
recurred  in  three  successive  pregnancies.  Marce  "distinguishes  between 
true  insanity  coming  on  during  pregnancy  and  aggravated  hypochon- 
driasis by  the  fact  that  the  latter  usually  lessens  after  the  third  month, 
while  the  former  most  commonly  only  begins  after  that  date.  It  is 
unquestionable  that  in  many  cases  no  such  distinction  can  be  made,  and 
that  the  two  are  often  very  intimately  associated. 
I  Form  of  Insanity. — The  form  of  insanity  does  not  differ  from  ordinary 
I  mejancholia.  The  suicidal  tendency  is  generally  very  strongly  developed. 
Should  the  mental  disorder  continue  after  delivery,  the  patient  may  very 
I  probably  experience  a  strong  impulse  to  kill  her  child.  Moral  perver- 
sions have  not  been  uncommonly  observed.  Tuke  especially  mentions 
a  tendency  to  dipsomania  in  the  early  months,  even  in  women  who  have 
not  shown  any  disposition  to  excess  at  other  times.  He  suggests  that 
this  may  be  an  exaggeration  of  the  depraved  appetite  or  morbid  craving 
so  commonly  observed  in  pregnant  women,  just  as  melancholia  may  be 
a  further  development  of  lowuiess  of  spirits.  Laycock  mentions  a  dis- 
position to  "  kleptomania"  as  very  characteristic  of  the  disease.  Casper^ 
relates  a  curious  case  where  this  occurred  in  a  pregnant  lady  of  rank, 
and  the  influence  of  pregnancy  in  developing  an  irresistible  tendency  was 
pleaded  in  a  criminal  trial  in  which  one  of  her  petty  thefts  had  involved 
her. 

Prognosis. — The  prognosis  may  be  said  to  be,  on  the  whole,  favorable. 
Out  of  Dr.  Tuke's  28  cases,  19  recovered  within  six  months.     There  is 
little  hope  of  a  cure  until  after  the  termination  of  the  pregnancy,  as,  out 
of  1 9  cases  recorded  by  Marce,  only  in  2  did  the  insanity  disappear  before 
delivery. 
/       Transient  Mania  during  Delivery. — There  is  a  peculiar  form  of  mental 
/   derangement  sometimes  observed  during  labor  which  is  by  some  talked 
1   of  as  a  temporary  insanity.     It  may,  perhaps,  be  more  accurately  de- 
scribed as  a  kind  of  acute  delirium,  produced,  in  the  latter  stage  of 
labor,  by  the  intensity  of  the  suflFering  caused  by  the  pains.     According 
to  Montgomery,  it  is  most  apt  to  occur  as  the  head  is  passing  through 
^tlie  OS  uteri,  or,  at  a  later  period,  during  the  expulsion  of  the  child.     It 

^  ArcJrivfilr  Psychialrie,  Band  v.  Heft  2. 

^  Casper's  Forenaic  Medicine,  New  Syd.  Soc,  vol.  iv.  p.  308. 


PUERPERAL  INSANITY.  585 

may  consist  of  merely  a  loss  of  control  over  the  mind,  during  which  the 
patient,  unless  carefully  watched,  might  in  her  agony  seriously  injure 
herself  or  her  child.  Sometimes  it  produces  actual  hallucination,  as  in- 
the  case  described  by  Tarnier  in  which  the  patient  fancied  she  saw  a 
spectre  standing  at  the  foot  of  her  bed,  which  she  made  violent  efforts  to 
drive  away.  This  kind  of  mania,  if  it  may  be  so  called,  is  merely  transi- 
tory in  its  character,  and  disappears  as  soon  as  the  labor  is  over.  From 
a  medico-legal  point  of  view  it  may  be  of  importance,  as  it  has  been  held 
by  some  that  in  certain  cases  of  infanticide  the  mother  has  destroyed  the 
child  when  in  this  state  of  transient  frenzy  and  when  she  was  irresponsi- 
ble for  her  acts.  In  the  treatment  of  this  variety  of  delirium  we  must, 
of  course,  try  to  lessen  the  intensity  of  the  suffering,  and  it  is  in  such  cases 
that  chloroform  will  find  one  of  its  most  valuable  applications. 

Puerperal  Insanity  {projyer). — True  puerperal  insanity  has  always 
attracted  much  attention  from  obstetricians,  often  to  the  exclusion  of 
other  forms  of  mentai  disturbance  connected  with  the  puerperal  state. 
We  may  define  it  to  be  that  form  of  insanity  which  comes  on  within  a 
limited  period  after  delivery,  and  which  is  probably  intimately  connected 
wdth  that  process.  Out  of  73  examples  of  the  disease  tabulated  by  Dr.. 
Tuke,  only  2  came  on  later  than  a  month  after  delivery,  and  in  these 
there  were  other  causes  present  which  might  possibly  remove  them  from 
this  class. 

Although  a  large  number  of  these  cases  assume  the  character  of  acute 
mania,  that,  is  by  no  means  the  only  kind  of  insanity  which  is  observed, 
a~nor  inconsiderable  number  being  well-marked  examples  of  melan- 
cholia. The  distinction  between  them  was  long  ago  pointed  out  by  J 
Gooch,  whose  admirable  monograph  on  tlie  disease  contains  one  of  the 
most  graphic  and  accurate  accounts  of  puerperal  insanity  that  has  yet 
been  ^vritten. 

There  are  also  some  peculiarities  as  to  the  period  at  which  these  varie- 
ties of  insanity  show  themselves,  which,  taken  in  connection  with  certain 
facts  in  their  etiology,  may  eventually  justify  us  in  drawing  a  stronger 
line  of  demarcation  between  them  than  has  been  usual.  It  appears  that 
cases  of  acute  mania  are  apt  to  come  on  at  a  period  much  nearer  delivery 
than  melancholia.  Thus,  Tuke  found  that  all  the  cases  of  mania  came 
on  within  sixteen  days  after  delivery,  and  that  all  cases  of  melancholia 
developed  themselves  after  that  period.  We  shall  presently  see  that  one 
of  the  most  recent  theories  as  to  the  causation  of  the  disease  attributes  it 
to  some  morbid  condition  of  the  blood.  Should  further  investigation 
confirm  this  supposition,  inasmuch  as  septic  conditions  of  the  blood 
are  most  likely  to  occur  a  short  time  after  labor,  it  would  not  be  an 
improl>able  hypothesis  that  cases  of  acute  mania  occurring  within  a  short 
time  after  labor  njay  depend  on  suc^h  septic  causes,  while  melancholia  is 
more  likely  to  arise  from  general  conditions  favoring  the  development 
of  mental  disease.  Tliis  nuist,  however,  be  regarded  as  a  mere  si)ecula- 
tion  requiring  further  investigation. 

Caufies. — Hereditary  predisposition  is  very  frequently  met  with,  and 
a  careful  inquiry  into  the  ])atient's  liistory  will  generally  show  that  other 
members  of  th(!  family  hav(!  suffered  from  mental  derangement.  Reid 
found  that  out  of  1  1  1  (uses  in  Ijethleheni  Hospital  there  was  clear  evi- 


586  THE  PUERPERAL  STATE. 

dence  of  hereditary  taint  in  45.  Tuke  made  the  same  observation  in  22 
out  of  his  73  cases ;  and,  indeed,  it  is  pretty  generally  admitted  by  all 
alienist  physicians  that  hereditary  tendencies  form  one  of  the  strongest 
predisposing  causes  of  mental  disturbance  in  the  puerperal  state.  In  a 
large  proportion  of  cases  circumstances  producing  debility  and  exhaus- 
tion or  mental  depression  have  preceded  the  attack.  Thus,  it  is  often 
found  that  patients  attacked  with  it  have  had  post-jjartumJiemoiTl^^ 
or  have  suffered  from  some  other  conditions  producing  exhaustion,  such 
as  severe  and  complicated  labor,  or  they  may  have  been  weakened  by 
over-frequent  pregnancies,  or  by  lactation  during  the  early  months  of 
I  pregnancy.  Indeed,_an8emia  is  always  well  marked  in  this  disease. 
Mental  conditions  also  are  frequently  traceable  in  connection  with  its 
production.  Morbid  dread  during  pregnancy,  insufficient  to  produce 
insanity  before  delivery,  may  develop  into  mental  derangement  after  it. 
Shame  and  fear  of  exposure  in  unmarried  women  not  unfrequently  lead 
to  it,  as  is  evidenced  by  the  fact  that  out  of  2281  cases,  gathered  from 
the  reports  of  various  asylums,  above  64  per  cent,  were  unmarried.^ 
Sudden  moral  shocks  or  vivid  mental  impressions  may  be  the  determin- 
ing cause  in  predisposed  persons.  Gooch  narrates  an  example  of  this 
in  a  lady  who  was  attacked  immediately  after  a  fright  produced  by  a 
fire  close  to  her  house,  the  hallucinations  in  this  case  being  all  connected 
with  light ;  and  Tyler  Smith,  that  of  another  whose  illness  dated  from 
the  sudden  death  of  a  relative.  The  age  of  the  patient  has  some  influ- 
ence, and  there  seems  to  be  a  decidedly  greater  liability  at  advanced 
ages,  especially  when  such  women  are  pregnant  for  the  first  time. 

Theory  of  its  Dependence  on  a  Morbid  State  of  the  Blood. — The  possi- 
bility of  the  acute  form  of  puerperal  insanity,  coming  on  shortly  after 
delivery,  being  dependent  on  some  form  of  septicaemia  is  one  Avhich 
deserves  careful  consideration.  The  idea  originated  with  Sir  James 
Simpson,  who  found  albumen  in  the  urine  of  four  patients.  He  sug- 
gested that  this  might  properly  indicate  the  presence  in  the  blood  of  cer- 
tain urinary  constituents  which  might  have  determined  the  attack,  much 
in  the  same  way  as  in  eclampsia.  Dr.  Donkin  subsequently  wrote  an 
important  paper,^  in  which  he  warmly  supported  this  theory,  and 
arrived  at  the  conclusion  '^  that  the  acute  dangerous  class  of  cases  are 
examples  of  ursemic  blood-poisoning,  of  which  the  mania,  rapid  pulse, 
and  other  constitutional  symptoms  are  merely  the  phenomena  ;  and  that 
the  affection,  therefore,  ought  to  be  termed  ursemic  or  renal  puerperal 
mania  in  contradistinction  to  the  other  form  of  the  disease."  He  also 
suggests  that  the  immediate  poison  may  be  carbonate  of  ammonia, 
resulting  from  the  decomposition  of  urea  retained  in  the  blood.  It  will 
be  observed,  therefore,  that  the  pathological  condition  producing  puer- 
peral mania  would,  supposing  this  theory  to  be  correct,  be  precisely  the 
same  as  that  which  at  other  times  is  supposed  to  give  rise  to  puerperal 
eclampsia.  There  can  be  no  doubt  that  the  patient  immediately  after 
delivery  is  in  a  condition  rendering  her  peculiarly  liable  to  various 
forms  of  septic  disease ;  and  it  must  be  admitted  that  there  is  no  inher- 
ent improbability  in  the  supposition  that  some  morbid  material  circulat- 
ing in  the  blood  may  be  the  effective  cause  of  the  attack  in  a  person 
1  Journ.  of  Mental  Science,  1870-71,  p.  159.  ^  j^^in,  Med.  Joitrn.,  vol.  vii. 


PUERPERAL  INSANITY.  587 

otherwise  predisposed  to  it.  It  is  also  certain,  as  I  have  already  pointed 
out,  that  there  are  two  distinct  classes  of  cases,  differing  according  to  the 
period  after  delivery  at  which  the  attack  comes  on.  Whether  this  dif- 
ference depends  on  the  presence  in  the  blood  of  some  septic  matter — 
especially  urinary  excreta — is  a  question  which  our  knowledge  by  no 
means  justifies  us  in  answering;  it  is,  however,  one  which  well  merits 
further  careful  study. 

Objections  to  this  Theory. — It  is  only  fair  to  point  out  some  difficul- 
ties which  appear  to  militate  against  the  view  which  Dr.  Donkin  main- 
tains. In  the  first  place,  the  albuminuria  is  merely  transient,  while  its 
supposed  effects  last  for  weeks  or  months.  Sir  James  Simpson  says, 
with  regard  to  his  cases,  "  I  have  seen  all  traces  of  albuminuria  in  puer- 
peral insanity  disappear  from  the  urine  within  fifty  hours  of  the  access 
of  the  malady.  The  general  rapidity  of  its  disappearance  is  perhaps  the 
principal — or  indeed  the  only — reason  why  this  complication  has  escaped 
the  notice  of  those  physicians  ^mong  us  who  devote  themselves  with 
such  ardor  and  zeal  to  the  treatment  of  insanity  in  our  public  asylums." 
This  apparent  anomaly  Simpson  attempts  to  explain  by  the  hypothesis 
that  when  once  the  urgemic  poisoning  has  done  its  work  and  set  the  dis- 
ease in  progress,  the  mania  progresses  of  itself.  This,  however,  is  pure 
speculation,  and  in  the  supposed  analogous  case  of  eclampsia  the  albu- 
minuria certainly  lasts  as  long  as  its  effects.  It  is  not  easy  to  under- 
stand, also,  why  ursemic  poisoning  should  in  one  case  give  rise  to  insan- 
ity and  in  another  to  convulsions.  For  all  we  know  to  the  contrary, 
transient  albuminuria  may  be  much  more  common  after  delivery  than 
has  been  generally  supposed,  and  further  investigation  on  this  point  is 
required.  Albumen  is  by  no  means  unfrequently  observed  in  the  urine, 
for  a  short  time,  in  various  conditions  of  the  body,  without  any  serious 
consequences,  as,  for  example,  after  bathing ;  and  we  may  too  readily 
draw  an  unjustifiable  conclusion  from  its  detection  in  a  few  cases  of 
mania.  There  are,  however,  many  other  kinds  of  blood-poisoning 
besides  uraemia  which  may  have  an  influence  in  the  production  of  the 
disease,  and  it  is  to  be  hoped  that  future  observations  may  enable  us  to 
speak  with  more  certainty  on  this  point. 

Prognosis. — The  prognosis  of  puerperal  insanity  is  a  point  which  will 
always  deeply  interest  those  who  have  to  deal  with  so  distressing  a 
malady.  It  may  resolve  itself  into  a  consideration  of  the  immediate 
risk  to  life  and  of  the  chances  of  ultimate  restoration  of  the  mental  fac- 
ulties. It  is  an  old  a])horism  of  Gooch's — and  one  the  correctness  of 
Avliich  is  justified  by  modern  exj^erience — that  "mania  is  more  danger- 
ous to  life,  melancholia  to  reason."  It  has  very  generally  been  supposed 
that  the  immediate  risk  to  life  in  puerperal  mania  is  not  great ;  and  on^ 
the  whole  this  may  be  taken  as  correct.  Tuke  found  that  death  took 
place,  from  all  causes,  in  10.9  per  cent,  of  the  cases  under  observation  ; 
tiiese,  however,  were  all  women  who  had  been  admitted  into  asylums, 
and  in  whom  tlu;  atta(;k  may  be  assumed  to  have  been  exce])tionally 
sev(!r(!.  (jtHiat  stress  was  hiid  by  Hunter  and  Gooc^h  on  extreme  rapid- 
ity of  the  j)nlse  as  indicating  a  fatal  tendency.  There  can  be  no  doubt 
that  it  is  a  symptom  of  great  gravity,  but  by  no  means  one  which  need 
lead  us  to  despair  of  our  {laticnt's  recovery.     The  most  dangerous  class 


588  THE  PUERPERAL  STATE. 

of  cases  are  those  attended  with  some  inflammatory  complication ;  and 
if  there  be  marked  elevation  of  temperature,  indicating  the  presence  of 
some  such  concomitant  state,  our  prognosis  must  be  more  grave  than 
when  there  is  mere  excitement  of  the  circulation. 

Post-mortem  Signs. — There  are  no  marked  post-mortem  signs  found 
in  fatal  cases  to  guide  us  in  forming  an  opinion  as  to  the  nature  of  the 
disease.  "  No  constant  morbid  changes,"  says  Tyler  Smith,  "are  found 
within  the*  head,  and  most  frequently  the  only  condition  found  in  the 
brain  is  that  of  unusual  paleness  and  exsanguinity.  Many  pathologists 
have  also  remarked  upon  the  extremely  empty  condition  of  the  blood- 
vessels, particularly  the  veins." 

Duration  of  the  Disease. — The  duration  of  the  disease  varies  consider- 
ably. Generally  speaking,  cases  of  mania  do  not  last  so  long  as  melan- 
cholia, and  recovery  takes  place  within  a  period  of  three  months,  often 
earlier.  Very  few  of  the  cases  admitted  into  the  Edinburgh  Asylum 
remained  there  more  than  six  months,,  and  after  that  time  the  chances 
of  ultimate  recovery  greatly  lessened.  When  the  patient  gets  well,  it 
often  happens  that  her  recollection  of  the  events  occurring  during  her 
illness  is  lost ;  at  other  times  the  delusions  from  which  she  suffered 
remain ;  as,  for  example,  in  a  case  which  was  under  my  care  in  which 
the  personal  antipathies  which  the  patient  formed  when  insane  became 
permanently  established. 

Insanity  of  Lactation. — 54  out  of  the  155  cases  collected  by  Dr.  Tuke 
were  examples  of  the  insanity  of  lactation,  which  would  appear,  there- 
fore, to  be  nearly  twice  as  common  as  that  of  pregnancy,  but  consider- 
1  ably  less  so  than  the  true  puerperal  form.     Its  dependence  on  causes 
I  producing  ansemia  and  exhaustion  is  obvious  and  well  marked.     In  the 
large  majority  of  cases  it  occurs  in  multiparse  who  have  been  debilitated 
_^  by  frequent  pregnancies  and  by  length  of  nursing.     When  occurring  in 
primaparse,  it  is  generally  in  women  who  have  suffered  from  post-partum 
hemorrhage  or  other  causes  of  exhaustion,  or  Avhose  constitution  was  such 
as  should  have  contraindicated  any  attempt  at  lactation.     The  bruit  de 
diable  is  almost  invariably  present  in  the  veins  of  the  neck,  indicating 
the  impoverished  condition  of  the  blood. 

The  type  is  far  more  frequently  melancholic  than  maniacal,  and  ^^•hen 

the  latter  form  occurs  the  attack  is  much  more  transient  than  in  true 

Lpuerperal  insanity.     The  danger  to  life  is  not  great,  especially  if  the 

cause  producing  debility  be  recognized  and  at  once  removed. 
j       There  seems,  however,  to  be  more  risk  of  the  insanity  becoming  per- 
l  manent  than  in  the  other  forms.    In  12  out  of  Dr.  Tuke's  cases  the  mel- 
ancholia degenerated  into  dementia,  and  the  patients  became  hopelessly 
insane. 

Symptoms. — The  symptoms  of  these  various  forms  of  insanity  ax'e 
practically  the  same  as  in  the  non-pregnant  state. 

In  Cases  of  Mania. — Generally,  in  cases  of  mania  there  is  more  or 
less  premonitory  indication  of  mental  disturbance,  which  may  pass  un- 
perceived.  The  attack  is  often  preceded  by  restlessness  and  loss  of  sleep, 
the  latter  being  a  very  common  and  well-marked  symptom,  or,  if  the 
patient  sleep,  her  rest  is  broken  and  disturbed  by  dreams.  Causeless 
dislikes  to  those  around  her  are  often  observed  :  the  nurse,  the  husband, 


PUERPERAL  INSANITY.  589 

the  doctor,  or  the  child  becomes  the  object  of  suspicion,  and,  unless 
proper  care  be  taken,  the  child  may  be  seriously  injured.  As  the  dis- 
ease advances  the  patient  becomes  incoherent  and  rambling  in  her  talk, 
and  in  a  fully-developed  case  she  is  incessantly  pouring  forth  an  uncon- 
nected jumble  of  sentences  out  of  which  no  meaning  can  be  made.  Often 
some  prevalent  idea  which  is  dwelling  in  the  patient's  mind  can  be  traced 
running  through  her  ravings,  and  it  has  been  noticed  that  this  is  fre- 
quently of  a  sexual  character,  causing  women  of  unblemished  reputation 
to  use  obscene  and  disgusting  language  which  it  is  difficult  to  under- 
stand their  even  having  heard.  The  tendency  of  such  patients  to  make 
accusations  impugning  their  own  chastity  was  specially  insisted  on  by 
many  eminent  authorities  in  a  recent  celebrated  trial,  when  Sir  James 
Simpson  stated  that  in  his  experience  "  the  organ  diseased  gave  a  type 
to  the  insanity,  so  that  with  women  suffering  from  affections  of  the  geni- 
tal organs  the  delusions  would  be  more  likely  to  be  connected  with  sexual 
matters."  Religious  delusions — as  a  fear  of  eternal  damnation  or  of 
having  committed  some  unpardonable  sin — are  of  frequent  occurrence, 
but  perhaps  more  often  in  cases  which  are  tending  to  the  melancholic  type. 
There  is  generally  intolerable  restlessness,  and  the  patient's  whole  man- 
ner and  appearance  are  those  of  excessive  excitement.  She  may  refuse 
to  remain  in  bed,  may  tear  off"  her  clothes,  or  may  attempt  to  injure 
herself.  The  suicidal  tendency  is  often  very  marked.  In  one  case  under 
my  care  the  patient  made  incessant  efforts  to  destroy  herself,  which  were 
only  frustrated  by  the  most  careful  watching ;  she  endeavored  to  strangle 
herself  with  the  bedclothes,  to  swallow  any  article  she  could  lay  hold  of, 
and  even  to  gouge  out  her  own  eyes.  Food  is  generally  persistently  re- 
fused, and  the  utmost  coaxing  may  fail  in  inducing  the  patient  to  take 
nourishment.  The  pulse  is  rapid  and  small,  and  the  more  violent  the 
excitement  and  furious  the  delirium  the  more  excited  is  the  circulation. 
The  tongue  is  coated  and  furred,  the  bowels  constipated  and  disordered, 
and  the  feces,  as  well  as  the  urine,  are  frequently  passed  involuntarily. 
The  urine  is  scanty  and  high-colored,  and  after  the  disease  has  lasted  for 
some  time  it  becomes  loaded  with  phosphates.  The  lochia  and  the  secre- 
tion of  milk  generally  become  arrested  at  the  commencement  of  the  dis- 
ease. The  waste  of  tissue,  from  the  incessant  restlessness  and  movement 
of  the  patient,  is  very  great,  and  if  the  disease  continue  for  some  time 
she  falls  into  a  condition  of  marasmus,  which  may  be  so  excessive  that 
she  becomes  wasted  to  a  shadow  of  her  former  size. 

Symptoms  of  Melancholia. — When  the  insanity  assumes  the  form  of 
melancholia  its  advent  is  more  gradual.  It  may  commence  with  depres- 
sion of  spirits  without  any  adequate  cause,  associated  with  insomnia,  dis- 
turbed digestion,  headache,  and  other  indications  of  bodily  derangement. 
Such  symjitoms,  showing  themselves  in  women  who  have  been  nursing 
for  a  length  of  time  or  in  whom  any  other  evident  cause  of  exhaustion 
exists,  should  never  ]>ass  unnoticed.  Soon  the  signs  of  mental  depres- 
sion increase  and  positive  delusions  show  themselves.  These  may  vary 
much  in  their  amount,  but  they  are  all  more  or  less  of  the  same  type, 
and  veiy  often  of  a  religi(jus  character.  The  amount  of  constitutional 
disturbance  varies  mucii.  In  some  cases  which  approach  in  character 
those  of  mania  there  is  considerable  excitement,  rapid  pulse,  furred 


590  THE  PUERPERAL  STATE. 

tongue,  and  restlessness.  Probably  cases  of  acute  melancholia  coming 
on  (luring  the  puerperal  state  most  often  assume  this  form.  In  others, 
again,  there  is  less  of  these  general  symptoms ;  the  patients  are  pro- 
foundly dejected,  sit  for  hours  without  speaking  or  moving ;  but  there 
is  not  much  excitement,  and  this  is  the  form  most  generally  characteriz- 
ing the  insanity  of  lactation.  In  all  cases  there  is  a  marked  disinclina- 
tion to  food.  There  is  also,  almost  invariably,  a  disposition  to  suicide ; 
and  it  should  never  be  forgotten  in  melancholic  cases  that  this  may  de- 
velop itself  in  an  instant,  and  that  a  moment's  carelessness  on  the  j^art 
of  the  attendants  may  lead  to  disastrous  results. 

Treatment. — Bearing  in  mind  what  has  been  said  of  the  essential  cha- 
racter of  puerperal  insanity,  it  is  obvious  that  the  course  of  treatment 
must  be  mainly  directed  to  maintain  the  strength  of  the  patient,  so  as  to 
enable  her  to  pass  through  the  disease  without  fatal  exhaustion  of  the 
vital  powers,  while  we  endeavor  at  the  same  time  to  calm  the  excitement 
and  give  rest  to  the  disturbed  brain.  Any  over-active  measures — for 
example,  bleeding,  blistering  the  shaven  scalp,  and  the  like — are  dis- 
tinctly contraindicated. 

There  is  a  general  agreement  on  the  part  of  alienist  physicians  that  in 
cases  of  acute  mania  the  two  things  most  needed  are  a  sufficient  quantity 
of  suitable  food  and  sleep. 

Importance  of  Administering  Nourishment. — Every  endeavor  should 
be  made  to  induce  the  patient  to  take  plenty  of  nourishment,  to  remedy 
the  defects  of  the  excessive  waste  of  tissue  and  support  her  strength 
until  the  disease  abates.  Dr.  Blandford,  who  has  especially  insisted  on 
the  importance  of  this,  says : '  "  Now,  with  regard  to  the  food,  skilful 
attendants  will  coax  a  patient  into  taking  a  large  quantity,  and  we  can 
hardly  give  too  much.  Messes  of  minced  meat  with  potato  and  greens, 
diluted  with  beef-tea,  bread  and  milk,  rum  and  milk,  arrowroot,  and  so 
on,  may  be  got  down.  Never  give  mere  liquids  so  long  as  you  can  get 
down  solids.  As  the  malady  progresses  the  tongue  and  mouth  may 
become  so  dry  and  foul  that  nothing  but  liquids  can  be  swallowed ;  but, 
reserving  our  beef-tea  and  brandy,  let  us  give  plenty  of  solid  food  while 
we  can." 

Forcible  Administration  of  Food. — The  patient  may  in  mania,  as  well 
as  in  melancholia — perhaps  even  more  in  the  latter — obstinately  refuse 
to  take  nourishment  at  all,  and  we  may  be  compelled  to  use  force.  Vari- 
ous contrivances  have  been  employed  for  this  purpose.  One  of  the  sim- 
plest is  introducing  a  dessert-spoon  forcibly  between  the  teeth,  the  patient 
being  controlled  by  an  adequate  number  of  attendants,  and  slowly  inject- 
ing into  the  mouth  suitable  nourishment  by  an  india-rubber  bottle  with 
an  ivory  nozzle,  such  as  is  sold  by  all  chemists.  Care  must  be  taken 
not  to  inject  more  than  an  ounce  at  a  time,  and  to  allow  the  patient  to 
breathe  between  each  deglutition.  So  extreme  a  measure  will  seldom 
be  required  if  the  patient  have  experienced  attendants  who  can  over- 
come her  resistance  to  food  by  gentler  means ;  but  it  may  be  essential, 
and  it  is  far  better  to  employ  it  than  to  allow  the  patient  to  become  ex- 
hausted from  want  of  nourishment.  In  one  case  I  had  to  feed  a  patient 
in  this  way  three  times  a  day  for  several  weeks,  and  used  for  the  pur- 

^  Blandford,  Insanity  and  its  Treatment. 


PUERPERAL  INSANITY. 


591 


pose  a  contrivance  known  in  asylums  as  Paley's  feeding-bottle,  which 
reduced  the  difficulty  of  the  process  to  a  minimum.  Beef-tea  or  strong 
soup  mixed  with  some  farinaceous  material,  such  as  Revalenta  Arabica, 
or  wheaten  flour  or  milk,  forms  the  best  mess  for  this  purpose. 

Stimulants. — In  the  early  stages  the  patient  is  probably  better  without 
stimulants,  which  seem  only  to  increase  the  excitement.  As  the  disease 
progresses  and  exhaustion  becomes  marked,  it  may  be  necessary  to  have 
recourse  to  them.  In  melancholia  they  seem  to  be  more  useful,  and  may 
be  administered  with  greater  freedom. 

State  of  the  Boioels. — The  state  of  the  bowels  requires  especial  atten- 
tion. They  are  almost  always  disordered,  the  evacuations  being  dark 
and  ofiFensive  in  odor.  In  the  early  stages  of  the  disease  the  prompt 
clearing  of  the  bowels  by  a  suitable  purgative  sometimes  has  the  effect 
of  cutting  short  an  impending  attack.  A  curious  example  of  this  is 
recorded  by  Gooch,  in  which  the  patient's  recovery  seemed  to  date  from" 
the  free  evacuation  of  the  bowels.  A  few  grains  of  calomel  or  a  dose 
of  compound  jalap  powder  or  of  castor  oil  may  generally  be  readily 
given.  During  the  continuance  of  the  illness  the  state  of  the  primae  viae 
should  be  attended  to,  and  occasional  aperients  will  be  useful,  but  strong 
and  repeated  purgation  is  hurtful,  from  the  debility  it  produces. 

The  Procuring  Sleep. — The  procuring  sleep  will  necessarily  form  one] 
of  the  most  important  points  of  treatment.     For  this  purpose  there  is  ' 
no  drug  so  valuable  as  the  hydrate  of  chloral,  either  alone  or  in  com-  ' 
bination  with  bromide  of  potassium,^hich  has  a  distinct  eifect  in  increas- 
ing its  hypnotic  action.     Given  in  a  full  dose  at,  bedtime — say  15  grs._^ 
to  3ss — it  rarely  fails  in  procuring  at  least  some  sleep,  and  in  an  early 
stage  of  acute  mania  this  may  be  followed  by  the  best  effects.     It  may 
be  necessary  to  repeat  this  draught  night  after  night  during  the  acute 
stage  of  the  malady.     If  we  cannot  induce  the  patient  to  swallow  the 
medicine,  it  may  be  given  in  the  form  of  enema. 

Question  of  Administering  Opiates. — It  is  generally  admitted  that  in 
mania  preparations  of  opium,  formerly  much  relied  on  in  the  treatment 
of  the  disease,  are  apt  to  doniore  harm  than  good-  Dr-  Blandford  gives_ 
a  strong  opinion  on  this  point.  He  says :  "  In  prolonged  delirious 
mania  I  believe  opium  never  does  good,  and  may  do  great  harm.  We 
shall  see  the  effects  of  narcotic  poisoning  if  it  be  pushed,  but  none  that 
are  beneficial.  This  applies  equally  to  opium  given  by  the  mouth  and 
by  subcutaneous  injection.  The  latter,  as  it  is  more  certain  and  effectual 
in  producing  good  results,  is  also  more  deadly  when  it  acts  as  a  narcotic 
poison.  After  the  administration  of  a  dose  of  morphia  by  the  subcu- 
taneous method  the  patient  will  probably  at  once  fall  asleep,  and  we  con- 
gratulate ourselves  that  our  long-wished-for  object  is  attained.  But 
after  half  an  hour  or  so  the  sleep  suddenly  terminates,  and  the  mania 
and  excitement  are  worse  than  before.  Here  you  may  possibly  think 
that,  liad  the  dose  been  larger,  instead  of  half  an  hour's  sleep  you  would 
have  obtained  one  of  longer  duration  ;  and  you  may  administer  more, 
but  with  a  like  result.  Large  doses  of  morphia  not  merely  fail  to  pro- 
duce refreshing  sleej) ;  they  poison  the  patient,  and  jiroduce,  if  not  the 
symptoms  of  actual  nai'cotic  ))oisoning,  at  any  rate  that  typhoid  condi- 
tion which  indicates  prostration  and  approaching  collapse.     I  believe 


592  THE  PUERPERAL  STATE. 

there  is  no  drug  the  use  of  wliich  more  often  becomes  abused  than  that 

I  of  opium. '^    It  is  otherwise_Jn  cases  ^f^melanchoHa,  especially  in  the 

I  more  chronic  forms.     In  these  opiates,  in  moderate  doses,  not  pushed  to 

/^excess,  may  be  given  with  great  advantage.    The  subcutaneous  injection 

of  morphia  is  by  far  the  best  means  of  exhibiting  the  drug,  from  its 

rapidity  of  action  and  facility  of  administration. 

Otiier  Calmatives. — There  are  other  methods  of  calming  the  excite- 
ment of  the  patient  besides  the  use  of  medicines.  The  prolonged  use 
of  the  warm  bath,  the  patient  being  immersed  in  water  at  a  temperature 
of  90°  or  92°  for  at  least  half  an  hour,  is  highly  recommended  by  some 
as  a  sedative.  The  wet  pack  serves  the  same  purpose,  and  is  more 
readily  applied  in  refractory  subjects. 

Importance  of  Judicious  Nursing. — Judicious  nursing  is  of  primary 

importance.     The  patient  should  be  kept  in  a  cool,  well-ventilated,  and 

somewhat  darkened  room.     If  possible  she  should  remain  in  bed,  or  at 

least  endeavors  should  be  made  to  restrain  the  excessive  restless  motion 

I  which  has  so  much  effect  in  promoting  exhaustion.     The  presence  of 

I  relatives  and  friends,  especially  the  husband,  has  generally  a  prejudicial 

[^and  exciting  effect ;  and  it  is  advisable  to  place  the  patient  under  the 

care  of  nurses  experienced  in  the  management  of  the  insane,  who,  as 

strangers,  are  likely  to  have  more  control  over  her.     It  is  not  too  much 

to  say  that  much  of  the  success  in  treatment  must  depend  on  the  manner 

in  which  this  indication  is  met.     Rough,  unskilled  nurses,  who  do  not 

know   how  to  use  gentleness  combined  with   firmness,  will   certainly 

aggravate  and  prolong  the  disorder.     Inasmuch  as  no  patient  should  be 

left  unwatched  by  day  or  night,  more  than  one  nurse  is  essential. 

Question  of  Removal  to  an  Asylum.. — The  question  of  the  removal  of 
the  patient  to  an  asylum  is  one  which  will  give  rise  to  anxious  considera- 
tion. As  the  fact  of  having  been  under  such  restraint  of  necessity  fixes 
a  certain  lasting  stigma  upon  a  patient,  this  is  a  step  which  every  one 
would  wish  to  avoid  if  possible.  In  cases  of  acute  mania,  which  will 
probably  last  a  comparatively  short  time,  home-treatment  can  generally 
be  efficiently  carried  out.  Much  must  depend  on  the  circumstances  of 
the  patient.  If  these  be  of  a  nature  which  preclude  the  possibility  of 
her  obtaining  thoroughly  efficient  nursing  and  treatment  in  her  own 
home,  it  is  advisable  to  remove  her  to  a  place  where  these  essentials  can 
be  obtained,  even  at  the  cost  of  some  subsequent  annoyance.  In  cases, 
of  chronic  melancholia,  the  management  of  which  is  on  the  whole  more 
difficult,  the  necessity  for  such  a  measure  is  more  likely  to  arise,  and 
should  not  be  postponed  too  late.  Many  examples  of  incurable  demen- 
tia arising  out  of  puerperal  melancholia  can  be  traced  to  unnecessary 
delay  in  placing  the  patients  under  the  most  favorable  conditions  for 
recovery. 

Treatment  during  Convalescence. — When  convalescence  is  commencing, 
change  of  air  and  scene  will  often  be  found  of  great  value.  Removal 
to  some  quiet  country  place,  wdiere  the  patient  can  enjoy  abundance  of 
air  and  exercise  in  the  company  of  her  nurses,  without  the  excitement 
of  seeing  many  people,  is  especially  to  be  recommended.  Great  caution 
must  be  used  in  admitting  the  visits  of  relatives  and  friends.  In  two 
cases  under  my  own  care  the  patients  relapsed,  when  apparently  pro- 


PUERPERAL  SEPTICEMIA.  593 

gressing  favorably,  because  the  husbands  insisted,  contrary  to  advice,  on 
seeing  them.  On  the  other  hand,  Gooch  has  pointed  out  that  when  the 
patient  is  not  recovering,  when  month  after  month  has  been  passed  in 
sechision  without  any  improvement,  the  visit  of  a  friend  or  relative  may 
produce  a  favorable  moral  impression  and  inaugurate  a  change  for  the 
better.  It  is  probably  in  cases  of  melancholia,  rather  than  in  mania, 
that  this  is  likely  to  happen.  The  experiment  may  under  such  circum- 
stances be  worth  trying,  but  it  is  one  the  result  of  which  we  must  con- 


template with  some  anxiety. 


Mj4a.cX^ 


1~ 


CHAPTER  V. 

PUEKPERAL  SEPTICEMIA. 


Difference  of  Opinion  as  to  Puerperal  Fever. — There  is  no  subject  in 
the  whole  range  of  obstetrics  which  has  caused  so  much  discussion  and 
difference  of  opinion  as  that  to  which  this  chapter  is  devoted.  Under 
the  name  of  Puerperal  Fever  the  disease  we  have  to  consider  has  given 
rise  to  endless  controversy.  One  writer  after  another  has  stated  his 
view  of  the  nature  of  the  affection  with  dogmatic  precision,  often  on  no 
other  grounds  than  his  own  preconceived  notions  and  an  erroneous  inter- 
pretation of  some  of  the  post-mortem  appearances.  Thus,  one  states 
that  puerperal  fever  is  only  a  local  inflammation,  such  as  peritonitis ; 
others  declare  it  to  be  phlebitis,  metritis,  metro-peritonitis,  or  an  essen- 
tial zymotic  disease,  sid  generis,  which  affects  lying-in  women  only.  The 
result  has  been  a  hopeless  confusion,  and  the  student  rises  from  the 
study  of  the  subject  with  little  more  useful  knowledge  than  when  he 
began.  Fortunately,  modern  research  is  beginning  to  throw  a  little 
light  upon  this  chaos. 

Modern  Vieio  of  the  Disease. — The  whole  tendency  of  recent  investi- 
gation is  daily  rendering  it  more  and  more  certain  that  obstetricians  have 
been  led  into  error  by  the  special  virulence  and  intensity  of  the  disease, 
and  that  they  have  erroneously  considered  it  to  be  something  special  to 
the  puerperal  state,  instead  of  recognizing  in  it  a  form  of  septic  disease 
practically  identical  with  that  which  is  familiar  to  surgeons  under  the 
name  of  pyjemia  or  septicaemia. 

Objedion  to  the  Name  ^''Puerperal  Fever  J'' — If  this  view  be  correct, 
tlie  term  "puerperal  fever,"  conveying  the  idea  of  a  fever  such  as  typlius 
or  typhoid,  must  be  acknowledged  to  V)e  misleading,  and  one  that  should 
be  discarded  as  only  tending  to  confusion.  Before  discussing  at  lengtli 
the  reasons  which  render  it  probable  that  the  disease  is  in  no  way  spe- 
cific or  peculiar  to  the  ])uerp(!ral  state,  it  will  be  well  to  relate  briefly 
some  of  tl)(f  leading  facts  coinKicted  with  it. 

ITistory  of  tli.r.  iJiseasc. — More  or  less  distinct  references  to  the  (exist- 
ence of  the  so-called  puerperal  fever  are  met  with  in  the  classical  authors, 
88 


594  THE  PUERPERAL   STATE. 

proving,  beyond  doubt,  that  the  disease  was  well  known  to  them  ;  and 
Hij)pocrates,  besides  relating  several  cases  the  nature  of  which  is  unques- 
tionable, clearly  recognizes  the  possibility  of  its  originating  in  the  reten- 
tion and  decomposition  of  portions  of  the  placenta.  Although  Harvey 
and  other  writers  showed  that  they  were  more  or  less  familiar  with  it, 
and  even  made  most  creditable  observations  on  its  etiology,  it  was  not 
until  the  latter  half  of  the  last  century  that  it  came  prominently  into 
notice.  At  that  time  the  frightful  mortality  occurring  in  some  of  the 
principal  lying-in  hospitals,  especially  in  the  Hotel  Dieu  at  Paris, 
attracted  attention  ;  and  ever  since  the  disease  has  been  familiar  to 
obstetricians. 

Ilortality  resulting  from  it  in  Lying-in  Hospitals. — Its  prevalence  in 
hospitals  in  which  lying-in  women  are  congregated  has  been  constantly 
observed  both  in  this  country  and  abroad,  occasionally  producing  an 
appalling  death-rate ;  the  disease,  when  once  it  has  appeared,  frequently 
spreading  from  one  patient  to  another  in  spite  of  all  that  could  be  done 
to  arrest  it.  It  would  be  easy  to  give  many  startling  instances  of  this. 
Thus,  it  prevailed  in  London  in  the  years  1760,  1768,  and  1770  to  such 
an  extent  that  in  some  lying-in  institutions  nearly  all  the  patients  died. 
Of  the  Edinburgh  Infirmary  in  1773  it  is  stated  that  "almost  every 
woman  as  soon  as  she  was  delivered,  or  perhaps  about  twenty-four  hours 
after,  was  seized  with  it,  and  all  of  them  died,  though  every  method  was 
used  to  cure  the  disorder."  On  the  Continent,  where  the  lying-in  insti- 
tutions are  on  a  much  larger  scale,  the  mortality  was  equally  great. 
Thus  in  the  Maison  d'Accouchements  of  Paris  in  a  number  of  cliiFerent 
years  sometimes  as  many  as  1  in  3  of  the  women  delivered  died,  on  one 
occasion  10  women  dying  out  of  15  delivered.  Similar  results  were  ob- 
served in  other  great  continental  hospitals,  as  in  Vienna,  where,  in  1823, 
19  per  cent,  of  the  cases  died,  and,  in  1842,  16  per  cent. ;  and  in  Berlin 
in  1862  hardly  a  single  patient  escaped,  the  hospital  being  eventually 
closed. 

Shoidd  Lying-in  Hospitals  be  Abolished  f — Such  facts,  the  correctness 
of  which  is  beyond  any  question,  prove  to  demonstration  the  great  risk 
which  may  accompany  the  aggregation  of  lying-in  women.  AVhether 
they  justify  the  conclusion  that  all  lying-in  hospitals  should  be  abolished 
is  another  and  a  very  wide  question  which  can  scarcely  be  satisfactorily 
discussed  in  a  practical  work.  It  is  to  be  observed,  however,  that  most 
of  the  cases  in  which  the  disease  produced  such  disastrous  results  oc- 
curred before  our  more  recent  knowledge  of  its  mode  of  propagation  was 
acquired,  when  no  sufficient  hygienic  precautions  were  adopted,  when 
ventilation  was  little  thought  of,  and  when,  in  a  word,  every  condition 
prevailed  that  would  tend  to  fiivor  the  spread  of  a  contagious  disease 
from  one  patient  to  another.  More  recent  experience  proves  that  when 
the  contrary  is  the  case  (as,  for  example,  in  such  an  institution  as  the 
Rotunda  Hospital  in  Dublin),  the  occurrence  of  epidemics  of  this  kind 
may  be  entirely  prevented  and  the  mortality  approximated  to  that  of 
home-practice. 

The  Assumption  of  a  Puerperal  Miasm  is  Unnecessary. — The  more 
closely  the  history  of  these  outbreaks  in  hospitals  is  studied,  the  more 
apparent  does  it  become  that  they  are  not  dependent  on  any  miasm 


PUERPERAL  SEPTICAEMIA.  595 

necessarily  produced  by  the  aggregation  of  puerperal  patients,  but  on  the 
direct  conveyance  of  septic  matter  from  one  patient  to  another. 

In  numerous  instances  the  disease  has  been  said  to  be  generally  epi- 
demic in  domiciliary  practice,  much  in  the  same  way  as  scarlet  fever  or 
any  zymotic  complaint  might  be.  Such  epidemics  are  described  as  hav- 
ing occurred  in  London  in  1827-28,  in  Leeds  in  1809-12,  in  Edinburgh 
in  1825,  and  many  others  might  be  cited.  There  is,  however,  no  suffi- 
cient ground  for  believing  that  the  disease  has  ever  been  epidemic  in  the 
strict  sense  of  the  word.  Tliat  numerous  cases  have  often  occurred  in 
the  same  place  and  at  the  same  time  is  beyond  question ;  but  this  can 
easily  be  explained  without  admitting  an  epidemic  influence,  knowing  as 
we  do  how  readily  septic  matter  may  be  conveyed  from  one  patient  to 
another.  In  many  of  the  so-called  epidemics  the  disease  has  been  lim- 
ited to  the  patients  of  certain  midwives  or  practitioners,  while  those  of 
others  have  entirely  escaped — a  fact  easily  understood  on  the  assumption 
of  the  disease  being  produced  by  septic  matter  conveyed  to  the  patient, 
but  irreconcilable  with  the  view  of  general  epidemic  influence.  We  are 
not  in  possession  of  any  reliable  statistics  of  the  mortality  arising  from 
puerperal  septicaemia  in  ordinary  general  practice.  It  has,  however, 
been  well  pointed  out,  in  the  Report  on  Puerperal  Fever  presented  by 
the  Obstetrical  Society  of  Berlin  to  the  Prussian  Minister  of  Health,^ 
that  not  only  do  the  published  returns  of  death  from  metria  afford  no 
reliable  estimate  of  the  actual  mortality  from  this  source,  but  that  they 
are  very  far  more  numerous  than  deaths  from  any  other  cause  in  con- 
nection with  pregnancy  and  childbirth. 

Numerous  Theories  advanced  regarding  its  Nature. — It  would  be  a 
useless  task  to  detail  at  length  the  theories  that  have  been  advanced  to 
explain  the  disease.  Indeed,  it  may  safely  be  held  that  the  supposed 
necessity  of  providing  a  theory  which  would  explain  all  the  facts  of  the 
disease  has  done  more  to  surround  it  with  obscurity  than  even  the  diffi- 
culties of  the  subject  itself  If  any  real  advance  is  to  be  made,  it  can 
only  be  by  adopting  a  humble  attitude,  by  admitting  that  we  are  only  on 
the  threshold  of  the  inquiry,  and  by  a  careful  observation  of  clinical 
facts,  without  drawing  from  them  too  positive  deductions. 

Theory  of  its  Local  Origin. — Many  have  taught  that  the  disease 
is  essentially  a  local  inflammation  producing  secondary  constitutional 
effects.  This  view  doubtless  originated  from  too  exclusive  attention  to 
the  morbid  changes  found  on  post-mortem  examination.  Excessive 
peritonitis,  phlebitis,  inflammation  of  the  lymphatics  or  of  the  tissues 
of  the  uterus,  are  very  commonly  foinid  after  death  ;  and  each  of  these 
has,  in  its  turn,  been  believed  to  l)e  the  real  source  of  the  disease.  This 
view  finds  l)ut  little  favor  with  modern  pathologists,  and  is  in  so  many 
ways  inconsistent  with  clinical  facts  that  it  may  be  considered  to  be 
obsolete.  No  one  of  the  conditions  above  mentioned  is  universally 
found,  and  in  tlic  worst  cases  definite  signs  of  local  inflammation  may 
he  entirfily  abs(!nt.  Nor  will  lliis  theory  <>xj)lain  tlie  conveyance  of  the 
disease  from  one  j)ati('nt  to  anothei',  or  the  peculiar  severity  of  the  con- 
stitutional symptoms. 

Thewy  of  an  Ksnenfiaf  Zymotic   Fm-r. — A   more  admissible  theory, 

'  See  Julin.  Med.  Journ.,  Nov.,  1878. 


596  THE  PUERPERAL  STATE. 

and  one  which  has  been  extensively  entertained,  is,  that  there  is  an 
essential  zymotic  fever  peculiar  to,  and  only  attacking,  puerperal  women, 
which  is  as  specific  in  its  nature  as  typhus  or  typhoid,  and  to  which  the 
local  phenomena  observed  after  death  bear  the  same  relation  that  the 
pustules  on  the  skin  do  to  small-pox  or  the  ulcers  in  the  intestinal 
glands  to  typhoid.  This  fever  is  supposed  to  spread  by  contagion  and 
infection,  and  to  prevail  epidemically,  both  in  private  and  in  hospital 
practice.  The  most  recent  exponent  of  this  view  is  Fordyce  Barker, 
who  in  his  excellent  work  on  the  Puerperal  Diseases  has  entered  at 
length  into  all  the  theories  of  the  disease.  He,  like  others  who  hold  his 
opinions,  has,  I  cannot  but  think,  entirely  failed  to  bring  forAvard  any 
conclusive  evidence  of  the  existence  of  such  a  siDCcific  fever.  It  is  n'o 
doubt  true  that  in  typhus  and  typhoid  and  other  undoubted  examples 
of  this  class  of  disease  there  are  well-marked  local  secondary  phenomena ; 
but  then  they  are  distinct  and  constant.  He  makes  no  attempt  to  prove 
that  anything  of  the  kind  occurs  in  puerperal  fever.  On  the  contrary, 
probably  there  are  no  two  cases  in  which  similar  local  phenomena  occur, 
nor  is  there  any  case  in  which  the  most  practised  obstetrician  could  fore- 
tell either  the  course  and  duration  of  the  illness  or  the  local  phenomenon. 
Again,  this  theory  altogether  fails  to  exj)lain  the  very  important  class  of 
cases  which  can  be  distinctly  traced  to  sources  originating  in  the  jmtient 
herself — viz.  the  absorption  of  septic  matter  from  decomposing  coagula 
and  the  like.  Barker  meets  this  difficulty  by  placing  such  cases  of  auto- 
infection  under  a  separate  category,  admitting  that  they  are  examples  of 
septicaemia.  But  he  fails  to  show  that  there  is  any  difference  in  symp- 
tomatology or  post-mortem  signs  between  them  and  the  cases  he  believes 
to  depend  on  an  essential  fever ;  nor  would  it  be  possible  to  distinguish 
the  one  from  the  other  by  either  their  clinical  or  pathological  history. 

Theory  of  its  Identity  with  Surgical  Septicaemia. — The  modern  view, 
which  holds  that  the  disease  is,  in  fact,  identical  with  the  condition 
known  as  pyaemia  or  septicaemia,  is  by  no  means  free  from  objections, 
and  much  patient  clinical  investigation  is  required  to  give  a  satisfactory 
explanation  of  certain  peculiarities  which  the  disease  presents ;  but  in 
spite  of  these  difficulties,  which  time  may  serve  to  remove,  it  offers  a  far 
better  explanation  of  the  phenomena  observed  than  any  other  that  has 
yet  been  advanced. 

According  to  this  theory,  the  so-called  puerperal  fever  is  produced  by 
the  absorption  of  septic  matter  into  the  system  through  solutions  of  con- 
tinuity in  the  generative  tract,  such  as  always  exist  after  labor.  It  is  not 
essential  that  the  poison  should  be  peculiar  or  specific,  for,  just  as  in  sur- 
gical pyaemia,  any  decomposing  organic  matter,  either  originating  within 
the  generative  organs  of  the  patient  herself  or  coming  from  without,  may 
set  up  the  morbid  action. 

In  describing  the  disease  under  discussion  I  shall  assume  that,  so  far 
as  our  present  knowledge  goes,  this  view  is  the  one  most  consonant  with 
facts ;  but,  bearing  in  mind  that  very  little  is  yet  known  of  surgical 
septicaemia,  it  must  not  be  expected  that  obstetricians  can  satisfactorily 
explain  all  the  phenomena  they  observe. 

Basis  of  Descrijjtion. — The  best  basis  of  description  I  know  of  is  that 
given  by  Burdon  Sanderson  when  he  says,  "  In  every  pyaemic  process 


P UEBPEBAL  SEPTICEMIA.  597 

you  may  trace  a  foctis,  a  centre  of  origin,  lines  of  diffusion  or  distribu- 
tion, and  secondary  results  from  the  distribution — in  every  case  an 
initial  process  from  which  infection  commences,  from  which  the  infection 
spreads,  and  secondary  processes  which  come  out  of  this  primary  one."  ^ 
Adopting  this  division,  I  shall  first  treat  of  the  mode  in  which  the 
infection  may  commence  in  obstetric  cases,  and  point  out  the  special  dif- 
ficulties which  this  part  of  the  subject  presents. 

Channels  through  lokich  Septic  Matter  may  he  Absorbed. — The  fact 
that  all  recently-delivered  women  present  lesions  of  continuity  in  the 
generative  tract,  through  which  septic  matter,  brought  into  contact  with 
them,  may  be  readily  absorbed,  has  long  been  recognized.  The  analogy 
between  the  interior  of  the  uterus  after  delivery  and  the  surface  of  a 
stump  after  amputation  was  particularly  insisted  on  by  Cruveilhier, 
Simpson,  and  others — an  analogy  which  was,  to  a  great  extent,  based  on 
erroneous  conceptions  of  what  took  place,  since  they  conceived  that  the 
whole  interior  of  the  uterus  was  bared.  It  is  now  well  known  that  that 
is  not  the  case ;  but  the  fact  remains  that  at  the  placental  site,  at  any 
rate,  there  are  open  vessels  through  which  absorption  may  readily  take 
place.  That  absorption  of  septic  material  occurs  through  this  channel  is 
probable  in  certain  cases  in  which  decomposing  materials  exist  in  the 
interior  of  the  uterus,  especially  when,  from  defective  uterine  contrac- 
tion, the  venous  sinuses  are  abnormally  patulous  and  are  not  occluded 
by  thrombi.  It  is  difficult  to  understand  how  septic  matter,  introduced 
from  without,  can  reach  the  placental  site.  Other  sites  of  absorption 
are,  however,  always  available.  These  exist  in  every  case  in  the  form 
of  slight  abrasions  or  lacerations  about  the  cervix,  or  in  the  vagina,  or, 
especially  in  primiparse,  about  the  fourchette  and  perineum.  There  is 
even  some  reason  to  think  that  absorption  of  septic  matter  may  take 
place  through  the  mucous  membrane  of  the  vagina  or  cervix  without 
any  breach  of  surface.  This  might  serve  to  account  for  the  occasional 
although  rare  cases  in  which  symptoms  of  the  disease  develop  themselves 
before  delivery,  or  so  soon  after  it  as  to  show  that  the  infection  must 
have  preceded  labor ;  nor  is  there  any  inherent  improbability  in  the  sup- 
position that  septic  material  may  be  occasionally  absorbed  through  the 
unbroken  mucous  membrane,  as  is  certainly  the  case  with  some  poisons — 
for  example,  that  of  syphilis.  Hence  there  is  no  difficulty  in  recognizing 
the  similarity  of  a  lying-in  woman  to  a  patient  suffering  from  a  recent 
surgical  lesion,  or  in  understanding  how  septic  matter  conveyed  to  her 
during  or  shortly  after  labor  may  be  absorbed.  It  is  necessary,  how- 
ever, to  suppose  that  absorption  takes  place  immediately  or  very  shortly 
after  these  lesions  of  continuity  are  formed,  for  it  is  well  known  that  the 
power  of  absorption  is  arrested  after  they  have  commenced  to  heal. 
This  fact  may  explain  the  cases  in  which  sloughing  about  the  perineum 
or  vagina  exists  without  any  septicaemia  resulting,  or  the  for  from  un- 
common cases  in  which  an  intens(!ly  fetid  locliial  discliarge  maybe  pres- 
ent a  few  days  after  diilivery  without  any  inf(!cti()ii  taking  ])lace. 

Tiie  character  and  sour(!es  of  the  septic  matter  constitute  one  of  the 
most  ol>scure  questions  in  connection  with  septiciemia,  and  that  which  is 
most  open  to  discussion. 

•  (Jliriiral  7VavK(ictionK,  vol.  viii.  p.  108. 


598  THE  PUERPERAL  STATE. 

Division  into  Autogenetic  and  Heterogenetic  Cases. — The  most  practi- 
cal division'  of  the  subject  is  into  cases  in  which  the  septic  matter  origi- 
nates within  the  patient,  so  that  she  infects  herself,  the  disease  then  being 
properly  autogenetic ;  and  into  those  in  ^^'hich  the  septic  matter  is  con- 
veyed from  without,  and  brought  into  contact  with  absorptive  surfaces 
in  the  generative  tract,  the  disease  then  being  heterogenetic. 

Sources  of  Self-infection. — The  sources  of  auto-infection  may  be  vari- 
ous, but  they  are  not  difficult  to  understand.  Any  condition  giving  rise 
to  decomposition,  either  of  the  tissues  of  the  mother  herself,  of  matters 
retained  in  the  uterus  or  vagina  that  ought  to  have  been  expelled,  or 
decomposing  matter  derived  from  a  putrid  foetus,  may  start  the  septicse- 
mic  process.  Thus  it  may  happen  that  from  continuous  pressure  on  the 
maternal  soft  parts  during  labor  sloughing  has  set  in,  or  there  may  be 
already  decomposing  material  present  from  some  previous  morbid  state  of 
the  genital  tracts,  as  in  carcinoma.  A  more  common  origin  is  the  retention 
of  coagula  or  of  small  portions  of  membrane  or  of  placenta  in  the  interior 
of  the  uterus,  which  have  putrefied  from  access  of  air,  or  in  the  decom- 
position of  the  lochia.  That  the  retention  of  portions  of  the  placental 
tissue  has  at  all  times  been  the  cause  of  septicsemia  may  be  illustrated  by 
the  case  of  the  Duchesse  d'Orleans  (in  the  time  of  Louis  XIII. ),  who 
had  an  easy  labor,  but  died  of  childbed  fever.  An  examination  \vas 
made  by  the  leading  physicians  of  Paris,  in  their  report  of  which  it  was 
stated  :  "  On  the  right  side  of  the  womb  was  found  a  small  portion  of 
after-birth  so  firmly  adherent  that  it  could  be  hardly  torn  oiF  by  the 
finger-nails."  ^  The  reason  why  self-infection  does  not  more  often  occur 
from  such  sources,  since  more  or  less  decomposition  is  of  necessity  so 
often  present,  has  already  been  referred  to  in  the  fact  that  absorption  of 
such  matters  is  not  apt  to  occur  when  the  lesions  of  continuity  always 
existing  after  parturition  have  commenced  to  heal.  This  observation 
may  also  serve  to  explain  how  previous  bad  states  of  health,  by  inter- 
fering with  the  healthy  reparative  process  occurring  after  delivery,  may 
predispose  to  self-infection.  It  is  interesting  to  note  that  puerperal  sep- 
ticaemia arising  from  such  sources  is  not  limited  to  the  human  race.  In 
the  debate  on  pysemia  at  the  Clinical  Society,  Mr.  Hutchinson  recorded 
several  well-marked  examples  occurring  in  ewes,  in  whose  uteri  portions 
of  retained  placenta  were  found. 

Sources  of  Heterogenetic  Infection. — The  sources  of  septic  matter  con- 
veyed from  without  are  much  more  difficult  to  trace,  and  there  are  many 
facts  connected  with  heterogenetic  infection  which  are  very  difficult  to 
reconcile  with  theory,  and  of  which,  it  must  be  admitted,  we  are  not  yet 
able  to  give  a  satisfactory  explanation. 

It  is  probable  that  any  decomposing  organic  matter  may  infect,  but 
that  some  forms  operate  with  more  certainty  and  greater  virulence  than 
others. 

Influence  of  Cadaveric  Poisoning. — One  of  these,  which  has  attracted 
special  attention,  is  what  may  be  termed  cadaveric  poison,  derived 
from  dissection  of  the  dead  subject  in  the  anatomical  and  post-mortem 
theatres,  and  conveyed  to  the  genital  tract  by  the  hands  of  the  accou- 
cheur.    Attention  was  particularly  directed  to  this  source  of  infection 

^  Louise  Bourgeois,  by  Goodell. 


PUERPERAL  SEPTICAEMIA.  599 

by  the  observations  of  Semnielweiss,  who  shoM^ed  that  in  the  division  of 
the  Vienna  Lying-in  Hospital  attended  by  medical  men  and  students 
who  frequented  the  dissecting-rooms  the  mortality  was  seldom  less  than 
1  in  10,  while  in  the  division  solely  attended  by  women  the  mortality 
never  exceeded  1  in  34 ;  the  number  of  deaths  in  the  former  division  at 
once  falling  to  that  of  the  latter  so  soon  as  proper  precautions  and  means 
of  disinfection  were  used.  Many  other  facts  of  a  like  nature  have  since 
been  recorded  which  render  this  origin  of  puerperal  septicaemia  a  matter 
of  certainty.  An  interesting  example  is  related  by  Simpson  with  cha- 
racteristic candor  :  "  In  1836  or  1837,  Mr.  Sidey  of  this  city  had  a  rapid 
succession  of  five  or  six  oases  of  puerperal  fever  in  his  practice  at  a  time 
when  the  disease  was  not  known  to  exist  in  the  practice  of  any  other 
practitioners  in  the  locality.  Dr.  Simpson,  who  had  then  no  firm  or 
proper  belief  in  the  contagious  propagation  of  puerperal  fever,  attended 
the  dissection  of  Mr.  Sidey's  patients  and  freely  handled  the  diseased 
parts.  The  next  four  cases  of  midwifery  which  Dr.  Simpson  attended 
were  all  affected  with  puerperal  fever,  and  it  was  the  first  time  he  had 
seen  it  in  practice.  Dr.  Patterson  of  Leith  examined  the  ovaries,  etc. 
The  three  next  cases  which  Dr.  Patterson  attended  in  that  town  were 
attacked  with  the  disease."  ^  Negative  examples  are  of  course  brought 
forward  of  those  who  have  attended  post-mortem  examinations  without 
injury  to  their  obstetric  patients,  which  merely  prove  that  the  cadaveric 
poison  does  not,  of  necessity,  attach  itself  to  the  hands  of  the  dissector ; 
and  no  amount  of  such  testimony  can  invalidate  such  positive  evidence 
as  that  just  narrated.  Barnes  believes  that  there  is  not  so  much  danger 
attending  the  dissection  of  patients  who  have  died  of  any  ordinary  dis- 
ease, but  that  the  risk  attending  the  dissection  of  those  who  have  died 
of  infectious  or  contagious  complaints  is  very  great  indeed.^  I  presume 
there  is  no  doubt  that  the  risk  is  greater  when  the  subject  has  died  from 
zymotic  disease,  but  the  distinction  is  too  delicate  to  rely  on  ;  and  the 
attendant  on  midwifery  will  certainly  err  on  the  safe  side  by  avoiding  as 
much  as  possible  having  anything  to  do  with  the  conduct  of  dissections 
or  post-mortem  examinations. 

Infection  from  Erysipelas. — Another  possible  source  of  infection  is 
erysipelatous  disease  in  all  its  forms.  The  intimate  connection  between 
erysipelas  and  surgical  pyaemia  has  long  been  recognized  by  surgeons, 
and  the  influence  of  erysipelas  in  producing  puerperal  septicaemia  has 
been  especially  observed  in  surgical  hospitals  into  which  lying-in 
patients  were  also  admitted.  Trousseau  relates  instances  of  this  kind 
occurring  in  Paris.  Tlic  only  instance  that  I  know  of  in  London  was 
in  tlio  lying-in  ward  of  King's  College  Hospital,  where,  in  spite  of  every 
liygicnif;  ])rccantion,  tlie  mortality  was  so  great  as  to  necessitate  the 
closure  of  the  ward.  Here  the  association  of  erysipelas  with  puerperal 
septicaemia  was  again  and  again  observed,  the  latter  proving  fatal  in 
<lircct  ])ro|)f)rtion  to  tlie  prevalence  of  the  former  in  the  surgical  wards. 
TIk!  de[)<'ndcn<'0  of  tlie  two  on  the  same  poison  was  in  one  instance  curi- 
ously shown  by  tlx;  fact  of  tlic  child  of  a  patient  who  died  of  ])uerperal 
soptica,'inia  dying  \nn\\   erysijxtlas  which  stiuix^d  from  a  slight  abrasion 

1  Sekctfd  ObHtet.  Workn,  p.  r,08. 

*"  Lectures  f)n  Piierper:il  l*Y'ver,"  Lancet,  vol.  ii.,  1805. 


600  THE  PUERPERAL  STATE. 

produced  by  the  forceps.  A  more  recent  and  very  remarkable  example 
is  related  by  Dr.  Lombe  Atthill.^  A  patient  sutfering  from  erysij^elas 
was  admitted  into  the  Rotunda  Hospital  on  February  15,  1877.  The 
sanitary  condition  of  the  hospital  %yas  at  the  time  excellent.  The 
patient  was  removed  next  day,  but  of  the  next  10  patients  confined  in 
adjoining  wards,  9  were  attacked  with  puerperal  peritonitis,  the  only 
one  who  escaped  being  a  case  of  abortion.  But  the  connection  between 
erysipelas  and  puerperal  septicaemia  is  not  limited  to  hospitals,  having 
been  often  observed  in  domiciliary  practice.  Some  interesting  facts  have 
been  collected  by  Dr.  Minor,^  who  has  shown  that  the  two  diseases  have 
frequently  prevailed  together  in  various  parts  of  the  United  States,  and 
that  during  a  recent  outbreak  of  puerperal  fever  in  Cincinnati  it  occurred 
chiefly  in  the  practice  of  those  physicians  who  attended  cases  of  erysipe- 
las. Many  children  also  died  from  erysipelas  whose  mothers  had  died 
from  puerperal  fever. 

Infection  from  other  Zymotic  Diseases. — There  is  good  reason  to 
believe  that  the  contagium  of  other  zymotic  diseases  may  produce  a  form 
of  disease  indistinguishable  from  ordinary  puerperal  septicaemia  and  pre- 
senting none  of  the  characteristic  features  of  the  specific  complaint  from 
which  the  contagium  was  derived.  This  is  admitted  to  be  a  fact  by  the 
majority  of  our  most  eminent  British  obstetricians,  although  it  does  not 
seem  to  be  allowed  by  continental  authorities,  and  it  is  strongly  contro- 
verted by  some  writers  in  this  country.  It  is  certainly  difficult  to  rec- 
oncile this  with  the  theory  of  septicaemia,  and  we  are  not  in  a  position 
to  give  a  satisfactory  explanation  of  it.  I  believe,  however,  that  the 
evidence  in  favor  of  the  possibility  of  puei^eral  sejjticaemia  originating 
in  this  way  is  too  strong  to  be  assailable. 

Cases  Produced  by  the  Contagion  of  Scarlet  Fever. — The  scarlatinal 
poison  is  that  regarding  which  the  greatest  number  of  observations  have 
been  made.  Numerous  ca*ses  of  this  kind  are  to  be  found  scattered 
through  our  obstetric  literature,  but  the  largest  number  are  to  be  met 
with  in  a  paper  by  Dr.  Braxton  Hicks  in  the  twelfth  volume  of  the 
Obstetriccd  Transactions ;  and  they  are  especially  valuable  from  that 
gentleman's  well-known  accuracy  as  a  clinical  observer.  Out  of  68 
cases  of  puerperal  disease  seen  in  consultation,  no  less  than  37  were  dis- 
tinctly traced  to  the  scarlatinal  poison.  Of  these,  20  had  the  character- 
istic rash  of  the  disease;  but  the  remaining  17,  although  the  history 
clearly  proved  exposure  to  the  contagium  of  scarlet  fever,  showed  none 
of  its  usual  symptoms,  and  w^ere  not  to  be  distinguished  from  ordinary 
typical  cases  of  the  so-called  puerperal  fever.  On  the  theory  that  it  is 
impossible  for  the  specific  contagious  diseases  to  be  modified  by  the 
puerperal  state,  we  have  to  admit  that  one  physician  met  with  17  cases 
of  puerperal  septicaemia  in  M'hich,  by  a  mere  coincidence,  the  contagion 
of  scarlet  fever  had  been  traced,  and  that  the  disease  nevertheless  origin- 
ated from  some  olher  source — an  hypothesis  so  improbable  that  its  mere 
mention  carries  its  own  refutation. 

Cases  Produced  by  the  Contagion  of  other  Zymotic  Diseases. — With 
regard  to  the  other  zymotic  diseases  the  evidence  is  not  so  strong,  pro1)a- 

^  Medical  Press  and  Cireidar,  April,  1877. 

^  Erysipelas  and  Childbed  Fever,  Cincinnati,  1874. 


PUERPERAL  SEPTICJSMIA.  601 

bly  from  the  comparative  rarity  of  the  diseases.  Hicks  mentions  one 
case  in  which  the  diphtheritic  poison  was  traced,  ahhough  none  of  the 
usual  phenomena  of  the  disease  were  present.  I  lately  saw  a  case  in 
which  a  lady  a  few  days  after  delivery  had  a  very  serious  attack  of  sep- 
ticaemia without  any  diphtheritic  symptoms,  her  husband  being  at  the 
same  time  attacked  with  diphtheria  of  a  most  marked  type.  Here  it 
would  be  difficult  not  to  admit  the  dependence  of  the  two  diseases  on 
the  same  poison. 

The  Zymotic  Diseases  are  not  always  Ifodifled  in  the  Puerperal  State. 
— It  is,  however,  certain  that  all  the  zymotic  diseases  may  attack  a 
newly-delivered  woman  and  run  their  characteristic  course  without  any 
peculiar  intensity.  Probably  most  practitioners  have  seen  cases  of  this 
kind ;  and  this  is  precisely  one  of  the  points  of  difficulty  which  we  can- 
not at  present  explain,  but  on  which  future  research  may  be  expected  to 
throw  some  light.  It  seems  to  me  not  improbable  that  the  explanation 
of  the  fact  that  zymotic  poison  may  in  one  puerperal  patient  run  its 
ordinary  course,  and  in  another  produce  symptoms  of  intense  septicsemia, 
may  be  found  in  the  channel  of  absorption.  It  is  at  any  rate  compre- 
hensible that  if  the  contagium  be  absorbed  through  the  skin  or  the 
ordinary  channel  it  may  produce  its  characteristic  symptoms  and  run  its 
usual  course,  while  if  brought  into  contact  with  lesions  of  continuity  in 
the  generative  tract  it  may  act  more  in  the  way  of  septic  poison,  or  with 
such  intensity  that  its  specific  symptoms  are  not  developed. 

It  may  reasonably  be  objected  that  if  puerperal  and  surgical  septicae- 
mia be  identical  the  zymotic  poisons  ought  to  be  similarly  modified 
when  they  infect  patients  after  surgical  operations.  The  subject  of 
specific  contagium  as  a  cause  of  surgical  pyjemia  has  been  so  little 
studied  that  I  do  not  think  any  one  would  be  justified  in  asserting  that 
such  an  occurrence  is  not  possible.  Fritsch  of  Halle  and  other  German 
physicians  have  recently  shown  how  elaborate  antiseptic  precautions  in 
lying-in  hospitals  may  prevent  the  origin  of  the  disease  from  such 
sources.  Sir  James  Paget,  in  his  Clinical  Lectures,  seems  to  believe  in 
the  possibility  of  such  modification.  He  says  :  "  I  think  it  not  improba- 
ble that  in  some  cases  results  occurring  with  obscure  symptoms  within 
two  or  three  days  after  operations  have  been  due  to  scarlet-fever  poison, 
hindered  in  some  w^ay  from  its  usual  progress."  Sir  Spencer  Wells 
informs  me  that  he  has  seen  cases  of  surgical  pysemia  which  he  had  rea- 
son to  believe  originated  in  the  scarlatinal  poison  ;  and  his  w^ell-known 
success  as  an  ovariotomist  is  no  doubt,  in  a  great  measure,  to  be  attrib- 
uted to  his  extreme  care  in  seeing  that  no  one  likely  to  come  in  contact 
with  his  patients  has  been  exposed  to  any  such  source  of  infection. 

Sewer  Gas  and  Defective  Sanitary  Arrangementii. — Exposure  to  sewer 
gas  may,  I  feel  sure,  produce  the  disease.  In  two  cases  of  the  kind  I 
had  the  opportunity  of  closely  watching  an  untrajiped  drain  opened 
directly  into  the  bedroom — in  one  instance  into  a  bath,  in  the  other  into 
a  water-closet.  Both  cases  were  indistinguishable  from  the  ordinary 
form  of  tlio  disease,  and  in  botli  lMi|)rovement  eonnnenced  as  soon  as  the 
patient  was  renKA'cd  into  anollici-  room. 

In  a  case  I  saw  some  years  ago  in  Notting  Hill  tlie  patient,  who  had 
been  confined  within  a  week,  liad  all  the  symptoms  of  a  most  intense 


602  THE  PUERPERAL  STATE. 

attack  of  septioiBmia,  but  none  of  a  diphtheritic  character,  while  her  hus- 
band lay  in  an  adjoining  room  suifering  from  a  diphtheritic  sore  throat. 
Here  the  waste-pipe  of  the  bath  was  found  to  counnunicate  directly  with 
the  sewer.  In  spite  of  her  intense  illness,  I  had  the  patient  removed  to 
another  house,  and  from  that  moment  she  began  to  improve.  In  two 
other  cases  in  which  the  same  source  of  disease  was  detected  the  removal 
of  the  patient  from  the  infected  atmosphere  was  immediately  followed 
by  a  marked  amelioration  in  the  symptoms.  I  know  of  three  similar 
oases  which  ended  fatally  in  which  I  have  every  reason  to  believe 
that  the  cause  of  the  disease  was  poisoning  by  sewer  gas.  Franken- 
hauser  has  related  a  curious  case  of  the  poisoning  of  four  puerperal 
I  women  by  sewer  gas.  In  fact,  the  whole  question  of  defective  sanitary 
conditions  on  the  puerperal  state  deserves  much  more  serious  study  than 
1  it  has  ever  yet  received,  and  I  have  long  been  satisfied  that  they  have 
1  ofben  much  to  do  with  certain  grave  forms  of  illness  in  the  lying-in  state 
the  origin  of  which  cannot  otherwise  be  traced. 

Septicoemia  from  Contagion  conveyed  from  other  Puerperal  Patients. — 
The  last  source  from  which  septic  matter  may  be  conveyed  is  from  a 
patient  suffering  from  puerperal  septicaemia — a  mode  of  origin  which 
has  of  late  attracted  special  attention.  That  this  is  the  explanation  of 
the  occasional  endemic  prevalence  of  the  disease  in  lying-in  hospitals  can 
scarcely  be  doubted.  The  theory  of  a  special  puerperal  miasm  pervad- 
ing the  hospital  is  not  required  to  account  for  the  facts,  for  there  are  a 
hundred  ways  impossible  to  detect  or  avoid — on  the  hands  of  nurses  or 
attendants,  in  sponges,  bed-pans,  sheets,  or  even  suspended  in  the  atmo- 
sphere— in  which  septic  material  derived  from  one  patient  may  be  carried 
to  another. 

The  poison  may  be  conveyed  in  the  same  manner  from  one  private 
patient  to  another.  Of  this  there  are  many  lamentable  instances  re- 
corded. Thus  it  was  mentioned  by  a  gentleman  at  the  recent  discussion 
at  the  Obstetrical  Society  that  5  out  of  14  women  he  attended  died,  no 
other  practitioner  in  the  neighborhood  having  a  case.  This  origin  of 
the  disease  was  clearly  pointed  out  by  Gordon^  toward  the  end  of  last 
century,  who  stated  that  he  himself  "  was  the  means  of  carrying  the 
infection  to  a  great  number  of  women ;"  and  he  also  traced  the  spread 
of  the  disease  in  the  same  way  in  the  practice  of  certain  midwives.  In 
some  remarkable  instances  the  unhappy  property  of  carrying  contagion 
has  clung  to  individuals  in  a  way  which  is  most  mysterious,  and  which 
has  led  to  the  supposition  that  the  whole  system  becomes  saturated  with 
the  poison.  One  of  the  strangest  cases  of  this  kind  was  that  of  Dr. 
Rutter  of  Philadelphia,  which  caused  much  discussion.  He  had  45 
cases  of  puerperal  septicaemia  in  his  own  practice  in  one  year,  while  none 
of  his  neighbors'  patients  were  attacked.  Of  him  it  is  related,  '^  Dr. 
Rutter,  to  rid  himself  of  the  mysterious  influence  which  seemed  to 
attend  upon  his  practice,  left  the  city  for  ten  days,  and  before  waiting  on 
the  next  parturient  case  had  his  hair  shaved  off  and  put  on  a  wig,  took 
a  hot  bath,  and  changed  every  article  of  his  apparel,  taking  nothing 
with  him  that  he  had  worn  or  carried  to  his  knowledge  on  any  former 
occasion  ;  and  mark  the  result.    The  lady,  notwithstanding  that  she  had 

^  See  Lectures  on  Puerperal  Fever,  by  Robert  J.  Lee,  M.  D. 


PUERPERAL  SEPTICEMIA.  603 

an  easy  parturition,  was  seized  the  next  day  with  childbed  fever,  and 
died  on  the  eleventh  day  after  the  birth  of  the  child.  Two  years  later 
he  made  another  attempt  at  self-purification,  and  the  next  case  attended 
fell  a  victim  to  the  same  disease."  No  wonder  that  Meigs,  in  comment- 
ing on  such  a  history,  refused  to  believe  that  the  doctor  carried  the  poi- 
son, and  rather  thought  that  he  was  "  merely  unhappy  in  meeting  with 
such  accidents  through  God's  providence."  It  appears,  however,  that 
Dr.  Rutter  was  the  subject  of  a  form  of  ozsena,  and  it  is  quite  obvious 
that  under  such  circumstances  his  hands  could  never  have  been  free  from 
septic  matter.^  This  observation  is  of  peculiar  interest,  as  showing  that 
the  sources  of  infection  may  exist  in  conditions  difficult  to  suspect  and 
impossible  to  obviate,  and  it  affords  a  satisfactory  explanation  of  a  case 
which  was  for  years  considered  puzzling  in  the  extreme.  It  is  quite 
possible  that  other  similar  cases — of  which  many  are  on  record,  although 
none  so  remarkable — may  possibly  have  depended  on  some  similar  cause 
personal  to  the  medical  attendant. 

The  sources  of  septic  poison  being  thus  multifarious,  a  few  words  may 
be  said  as  to  the  mode  in  which  it  may  be  conveyed  to  the  patient. 

Mode  in  which  the  Poison  may  be  Conveyed  to  the  Patient. — As  on  the 
view  of  puerperal  septicsemia  which  seems  most  to  agree  with  recorded 
facts  the  poison,  from  whatever  source  it  may  be  derived,  must  come 
into  actual  contact  with  lesions  of  continuity  in  the  generative  tract,  it 
is  obvious  that  one  method  of  conveyance  may  be  on  the  hands  of  the 
accoucheur.  That  this  is  a  possibility,  and  that  the  disease  has  often  been 
unhappily  conveyed  in  this  way,  no  one  can  doubt.  Still,  it  would  be 
unfair  in  the  extreme  to  conclude  that  this  is  the  only  way  in  which 
infection  may  arise.  In  town-practice,  especially,  there  are  many  other 
ways  in  which  septic  matter  may  reach  the  patient.  The  nurse  may  be 
the  means  of  communication,  and,  if  she  have  been  in  contact  with  sep- 
tic matter,  she  is  even  more  likely  than  the  medical  attendant  to  convey 
it  when  washing  the  genitals  during  the  first  few  days  after  delivery,  the 
time  that  absorption  is  most  apt  to  occur.  Barnes  relates  a  whole  series 
of  cases  occurring  in  a  suburb  of  London  in  the  practice  of  different 
practitioners,  every  one  of  which  was  attended  by  the  same  nurse. 
Again,  septic  matter  may  be  carried  in  sponges,  linen,  and  other  articles. 
What  is  more  likely,  for  example,  than  that  a  careless  nurse  might  use 
an  imperfectly-washed  sponge  on  which  discharge  has  been  allowed  to 
remain  and  decompose  ?  Nor  do  I  see  any  reason  to  question  the  possi- 
bility  of  infection  from  septic  matter  suspended  in  the  atmosphere;  and 
in  lying-in  hospitals,  where  many  women  are  congregated  together,  there 
can  be  little  doubt  that  this  is  a  crommon  origin  of  the  disease.  It  is  cer- 
tain, whatever  view  we  may  take  of  the  character  of  the  septic  material, 

'  This  is  stated  on  the  authority  of  an  obstetrical  conteini)orary  oi'  T)r.  Rutter.  (See 
Awer.  Journ.  of  ^Frd.  Sdrnrr,  April,  1875,  p.  474.) 

Tlie  aiitlior  quotes  from  tlie  editor.  I)r.  Ilutter  had  an  ozsena  whicli  in  time  mucli 
di.sligured  hiin  froiii  its  eflect  upon  the  contour  of  his  nose.  He  was  unfortunately 
inoculated  in  his  index;  finpfer  from  a  patient,  and  neglected  the  pusttde.  He  had  95 
cases  of  puerperal  septicnmia  in  four  years  and  nine  months,  with  IS  deaths.  The 
<|uestion  of  Dr.  Meigs,  who  was  a  non-contagionist  in  regard  to  j)Uorf»eral  peritonitis, 
was  remarkal)ly  apjjositc!:  "Did  he  distil  a  sulitle  essence  which  he  carried  with  him?" 
—  Harris's  note  to  tliii'd  Ainciiiaii  edition. 


604  THE  PUERPERAL  STATE. 

that  it  must  be  in  a  state  of  very  minute  subdivision,  and  tliere  is  no 
theoretical  difficulty  in  the  assumption  of  its  being  conveyed  by  the 
atmosphere. 

Conduct  of  the  Practitioner  in  Relation  to  the  Disease. — This  question 
naturally  involves  a  reference  to  the  duty  of  those  who  are  unfortunately 
brought  into  contact  with  septic  matter  in  any  form,  either  in  a  patient 
suffering  from  puerperal  septicsemia,  zymotic  disease,  or  offensive  dis- 
charges. The  practitioner  cannot  always  avoid  such  contact,  and  it  is 
practically  impossible  to  relinquish  obstetric  work  every  time  that  he  is 
in  attendance  on  a  case  from  which  contagion  may  be  carried.  Nor  do 
I  believe,  especially  in  these  days  when  the  use  of  antiseptics  is  so  well 
understood,  that  it  is  essential.  It  was  otherwise  when  antiseptics  were 
not  employed,  but  I  can  scarcely  conceive  any  case  in  which  the  risk  of 
infection  cannot  be  prevented  by  proper  care.  The  danger  I  believe  to 
be  chiefly  in  not  recognizing  the  possible  risk  and  in  neglecting  the  use 
of  proper  precautions.  It  it  impossible,  therefore,  to  urge  too  strongly 
the  necessity  of  extreme,  and  even  exaggerated,  care  in  this  direction. 
The  practitioner  should  accustom  himself,  as  much  as  possible,  to  use 
the  left  hand  only  in  touching  patients  suffering  from  infectious  diseases, 
as  that  which  is  not  used  under  ordinary  circumstances  in  obstetric  man- 
ipulations. He  should  be  most  careful  in  the  frequent  employment  of 
antiseptics  in  washing  his  hands,  such  as  Condy's  fluid,  carbolic  acid,  or 
the  1-in-lOOO  solution  of  perchloride  of  mercury.  Clothing  should  be 
changed  on  leaving  an  infectious  case.  Much  more  care  than  is  usually 
practised  should  be  taken  by  nurses,  especially  in  securing  perfect  clean- 
liness in  everything  brought  into  contact  with  the  patient.  When,  how- 
ever, a  practitioner  is  in  actual  and  constant  attendance  on  a  case  of 
puerperal  septicsemia — when  he  is  visiting  his  patient  Jiiany  times  a  day, 
especially  if  he  be  himself  washing  out  the  uterus  with  antiseptic  lotions 
— it  is  certain  that  he  cannot  deliver  other  patients  with  safety  ;  and  he 
should  secure  the  assistance  of  a  brother-practitioner,  although  there 
seems  no  reason  why  he  should  not  visit  women  already  confined  in 
whom  he  has  not  to  make  vaginal  examinations. 

Projjhijlaxis  of  Sejiticcemia. — If  the  views  here  inculcated  as  to  the 
nature  of,  and  mode  of  infection  in,  puerperal  septicsemia  be  correct,  it 
is  obvious  that  much  may  be  done  in  the  way  of  prophylaxis.  A  per- 
fectly aseptic  management  of  puerperal  women  is  practically  impossible. 
In  many  lying-in  institutions  on  the  Continent,  and  in  some  in  this 
country,  very  rigid  rules  have  been  laid  down  to  prevent  the  possibility 
of  infective  matter  being  conveyed  to  the  patient  either  on  the  hands  of 
the  attendants  or  on  instruments,  napkins,  and  the  like,  and,  it  is  said, 
with  very  satisfactory  results.  As  the  risk  is  nuich  greater  when  lying- 
in  women  are  collected  together,  such  precautions,  which  this  is  not  the 
place  to  discuss,  are  absolutely  indicated.  They  are  not,  however,  appli- 
cable in  ordinary  private  practice,  but  there  are  certain  simple  precautions, 
which  every  one  might  adopt  without  trouble,  which  will  materially 
lessen  the  risk  of  septic  poisoning.  Amongst  these  may  be  indicated 
the  use  of  antiseptic  lotions,  with  which  the  practitioner  and  nurse  should 
always  wash  their  hands  before  attending  any  case  or  touching  the  geni- 
tal organs ;  the  use  of  carbolized  oil,  l-in-8,  for  lubricating  the  fingers. 


PUERPERAL  SEPTICEMIA.  605 

catheter,  forceps,  etc. ;  syringing  ont  the  vagina  night  and  morning  with 
(lihited  Condy's  fluid ;  rigid  attention  to  cleanliness  in  bedding,  nap- 
kins, etc.  Precautions  such  as  these,  although  they  may  appear  to  some 
frivolous  and  useless,  indicate  a  recognition  of  danger  and  an  endeavor 
to  remove  it,  and,  if  they  were  generally  inculcated  on  nurses  (see  note, 
p.  555)  and  others,  might  go  far  to  prevent  the  occurrence  of  septic 
mischief. 

Nature  of  the  Septic  Poison. — As  to  the  precise  character  of  the  septic 
poison,  although  of  late  much  has  been  said  about  it,  and  there  is  good 
reason  to  believe  that  further  research  may  throw  light  on  this  obscure  sub- 
ject, too  little  is  known  to  justify  any  positive  statement.  With  regard  to 
the  influence  of  minute  micro-organisms  and  their  supposed  connection 
with  the  production  of  the  disease,  this  is  especially  the  case.  The 
recent  researches  of  Heiberg,  Von  Recklinghausen,  Steurer,  and  others 
have  shown  that  in  puerperal  septicaemia,  as  in  surgical  fever,  erysipelas, 
and  other  infectious  diseases,  chain-like  micrococci  in  large  numbers  may 
be  traced  passing  between  the  muscular  and  connective-tissue  fibres 
through  the  lymphatics,  and  thus  into  the  general  circulation,  and  that 
they  may  be  found  in  various  organs  and  pathological  products.  These 
observations  are  of  much  importance,  as  tending  to  confirm  by  scientific 
observation  the  intimate  relation  between  these  various  forms  of  disease 
which  has  long  been  believed  to  exist.  It  may  be  taken  as  certain  that 
these  bodies  bear  an  intimate  and  important  relation  to  the  disease ;  but 
whether  they  themselves  form  the  septic  matter  or  carry  it,  or  whether 
they  are  mere  accidental  concomitants  of  the  pysemic  processes,  it  is  im- 
possible, in  the  present  state  of  our  knowledge,  to  state,  and  I  therefore 
prefer  to  dwell  on  that  part  of  the  subject  which  is  of  clinical  import- 
ance, rather  than  enter  into  speculative  theories  which  may  to-morrow 
prove  to  be  valueless.^ 

Ohannels  of  Diffusion. — Passing  on  to  the  channels  of  diffusion  through 
which  the  septic  matter  may  act,  we  have  to  consider  its  effects  on  the 
structures  with  which  it  is  brought  into  contact  and  the  mode  in  which 
it  may  infect  the  system  at  large ;  and  this  will  include  a  consideration 
of  the  pathological  phenomena. 

Local  changes  consequent  on  the  absorption  of  the  poison  are  pretty 
constant,  and  of  these  we  may  form  an  intelligible  idea  by  thinking  of 
them  as  similar  in  character  and  causation  to  those  which  we  have  the 
opportunity  of  studying  when  septic  matter  is  applied  to  a  wound  open 
to  observation  ;  as,  for  example,  in  cases  of  blood-poisoning  following  a 
dissection  wound.  Distinct  traces  of  local  action  are  not  of  invariable 
occurrence,  and  in  some  of  the  worst  class  of  cases,  when  the  amount  of 
septic  matter  is  great  and  its  absorption  rapid,  death  may  occur  after  an 
illness  of  short  duration,  but  great  intensity,  and  before  apprc(!iable  local 
changes,  either  at  the  site  of  absorption  or  in  the  system  at  large,  have 
had  time  to  develop  tli{!msclves.  Tiie  fact  that  ])ucr])oral  fever  may 
prove  fatal  without  leaving  any  tangible  ]M)st-morlcm  signs  has  often 
been  pointed  out,  such  cases  most  fmpiently  occnriing  during  the  en- 

*  For  tlu!  Into.st  inforMKitifjn  on  tliis  point  hcc  "Onr  Present  Knowledge  of  tlie  Kela- 
tions  lietwf'fii  Mifi-o-oi-^.-misnis  and  Puerijcral  Fever,"  by  Carl  Loraer,  M.  D.,  Ainer. 
Journ.  of  (Jhdel.,  .July,  1884. 


()06  THE  PUERPERAL  STATE. 

demic  prevalence  of  the  disease  in  lying-in  hospitals.  There  can  be  little 
doubt,  however,  tliat  in  such  cases  of  intense  septicseniia  marked  patho- 
logical changes  exist  in  the  form  of  alterations  of  the  blood  and  degene- 
rations of  tissue,  but  not  of  a  character  which  can  be  detected  by  an 
ordinary  post-mortem  examination.  In  the  great  majority  of  cases  indi- 
cations of  the  disease  exist  at  the  site  of  absorption.  These  are  described 
by  pathologists  as  identical  in  their  character  with  the  inflammatory 
oedema  which  occurs  in  connection  with  phlegmonous  erysipelas.  If 
lacerations  exist  in  the  cervix  or  vagina,  they  take  on  unhealthy  action, 
their  edges  swell,  and  their  surfaces  become  covered  with  a  yellowish 
coat  similar  in  appearance  to  diphtheritic  membrane.  The  mucous 
membrane  of  the  uterus  is  also  generally  found  to  be  affected,  and  in 
a  degree  varying  with  the  intensity  of  the  local  septic  process.  There 
is  evidence  of  severe  endometritis,  and  very  frequently  the  whole  lining- 
of  the  uterus  is  profoundly  altered,  softened,  covered  with  patches  of 
diphtheritic  deposit,  and,  it  may  be,  in  a  state  of  general  necrosis.  In 
the  severer  cases  these  changes  affect  the  muscular  tissue  of  the  uterus, 
which  is  found  to  be  swollen,  soft,  imperfectly  contracted,  and  even 
partially  necrosed — a  condition  which  is  likened  by  Heiberg  to  hospital 
gangrene.  The  connective  tissue  surrounding  the  generative  tract  is  also 
swollen  and  oeclematous,  and  the  inflammation  may  in  this  way  reach 
the  peritoneum,  although  peritonitis,  so  often  observed  in  puerperal  sep- 
ticaemia, does  not  necessarily  depend  on  the  direct  transmission  of  inflam- 
mation from  the  pelvic  connective  tissue,  but  is  more  often  a  secondary 
phenomenon. 

Channels  through  ivhich  Systemic  Infection  is  Produced. — The  chan- 
nels through  which  general  systemic  infection  may  supervene  are  the 
lymphatics  and  the  venous  sinuses,  the  former  being  by  far  the  most 
important.  Recent  researches  have  shown  the  great  number  and  com- 
plexity of  the  lymphatics  in  connection  with  the  pelvic  viscera,  and 
marked  traces  of  the  absorption  of  septic  matter  are  almost  ahvays  to  be 
found,  except  in  those  very  intense  cases,  already  alluded  to,  in  which 
no  appreciable  post-mortem  signs  are  discoverable.  The  se])tic  matter 
is  probably  absorbed  from  the  lymph-spaces  abounding  in  the  connec- 
tive tissue,  and  carried  along  the  lymphatic  canals  to  the  nearest  glands. 
The  result  is  inflammation  of  their  coats  and  thrombosis  of  their  con- 
tents, which  may  be  seen  on  section  as  a  creamy,  purulent  substance. 
The  absorption  of  septic  material  may,  as  Virchow  has  shown,  be  de- 
layed by  the  local  changes  produced  in  the  lymphatics  and  in  the  glands 
with  which  they  communicate,  which  are  therefore  conservative  in  their 
action ;  and  the  further  progress  of  the  case  may  in  this  way  be  sto])ped 
and  local  inflammation  alone  result,  such  cases  being  believed  by  Hei- 
berg to  be  examples  of  abortive  jiyaemia.  On  the  other  hand,  the  free 
septic  material  may  be  too  abundant  and  intense  to  be  so  anTsted ;  it 
may  pass  on  through  the  lymph-canals  and  glands  until  it  reaches  the 
blood-current  through  the  thoracic  duct,  and  so  produces  a  general 
blood-infection.  This  mode  of  absorption  of  septic  matter,  and  the 
tendency  of  the  glands  to  arrest  its  further  progress,  serve  to  explain 
the  progressive  character  of  many  cases  in  which  fresh  exacerbations  seem 
to  occur  from  time  to  time,  since  fresh  quantities  of  poison,  generated  at 


PUERPERAL  SEPTICEMIA.  607 

its  source  of  origin,  may  be  absorbed  as  the  case  progresses.  The  ute- 
rine veins  are  supposed  by  D'Espine  to  be  the  channel  of  absorption  in 
the  intense  form  of  disease  which  proves  fatal  very  shortly  after  delivery, 
too  soon  for  the  more  gradual  process  of  lymphatic  absorption  to  have 
become  established.  It  is  evident  that  the  veins  are  not  likely  to  act  in 
this  way,  since  they  must,  under  ordinary  circumstances,  be  completely 
occluded  by  thrombi,  otherwise  hemorrhage  would  occur.  If,  however, 
uterine  contraction  be  incomplete,  the  occlusion  of  the  venous  sinuses 
may  be  imperfect,  and  absorption  of  septic  material  through  them  may 
then  take  place.  Some  writers  have  laid  great  stress  on  imperfect  ute- 
rine contraction  in  predisposing  to  septicsemia,  and  its  influence  may  thus 
be  well  explained.  The  veins  may  bear  an  important  part  in  the  produc- 
tion of  septicsemia  independent  of  the  direct  absorption  of  septic  matter 
through  them  by  means  of  the  detachment  of  minute  portions  of  their 
occluding  thrombi  in  the  form  of  emboli.  If  phlegmonous  inflammation 
occur  in  the  immediate  vicinity  of  the  veins,  the  thrombi  they  contain 
may  become  infected.  When  once  blood-infection  has  occurred  by  any 
of  these  channels,  general  septicsemia,  the  so-called  puerperal  fever,  is 
developed. 

Pathological  Phenomena  observed  after  General  Blood-Infection. — 
The  variety  of  pathological  phenomena  found  on  post-mortem  examina- 
tion has  had  much  to  do  with  the  prevalent  confusion  as  to  the  nature 
of  the  disease.  This  has  resulted  in  the  description  of  many  distinct 
forms  of  puerperal  fever,  the  most  marked  pathological  alteration  having 
been  taken  to  be  the  essential  element  of  the  disease.  As  a  matter  of 
fact,  there  is  no  doubt  that  various  types  of  pathological  change  are  met 
with.  Heiberg  describes  four  chief  classes  which  are  by  no  means  dis- 
tinctly separated  from  one  another,  are  often  found  simultaneously  in 
the  same  subject,  and  are  certainly  not  to  be  distinguished  by  the  symp- 
toms during  life. 

Intense  Cases  without  Marked  Post-mortem  Signs. — Of  these,  the  first 
is  the  class  of  cases  in  which  no  appreciable  morbid  phenomena  arei 
found  after  death.  This  formidable  and  fatal  form  of  the  disease  has 
long  been  well  known,  and  is  that  described  by  some  of  our  authors  as 
adynamic  or  malignant  puerperal  fever.  It  is  the  variety  which  was  so 
prevalent  in  our  lying-in  hospitals,  and  which  Ramsbotham  talks  of  as 
being  second  only  to  cholera  in  the  severity  and  suddenness  of  its  onset 
and  in  the  rapidity  with  which  it  carried  oiF  its  victims.  It  is  quite 
erroneous  to  suppose  that  the  existence  of  j^athological  changes  in  this 
form  of  disease  has  never  been  recognized.  Even  with  the  coarse  meth- 
ods of  examination  formerly  used,  the  occurrence  of  a  fluid  and  altered 
state  of  the  l)]ood  and  ecchymos(!s  in  connection  M'ith  various  organs — 
especially  the  lungs,  spleen,  and  kidneys — were  noticed  and  specially 
described  by  Copland  \\\\\\ii  Dictionary  of  Medicine.  More  recently  it 
has  been  clearly  proved  by  the  microscope  that  there  exists,  in  addition, 
the  commencement  of  inflammation  in  most  of  the  tissues,  shown  by 
cloudy  swellings  and  gnuiulin'  infiltnition  and  disintegration  of  the  cell- 
elements ;  proving  that  the  blood,  heavily  cliarged  with  se|)tic  innltcf, 
had  set  up  morbid  action  wherever  it  circulated,  the  patient  succumbing 
before  this  had  time  to  develop. 


608  THE  PUERPERAL  STATE. 

Cases  characterized  by  Inflammation  of  fJie  Serous  Membranes. — In  the 
second  type,  and  that  perhaps  most  commonly  met  with,  the  morbid 
changes  are  more  frequently  found  in  the  serous  membranes,  in  the  pleura, 
in  the  pericardium,  but,  above  all,  in  the  peritoneum,  the  alterations  in 
which  have  long  attracted  notice,  and  have  been  taken  by  many  writers 
as  proving  peritonitis  to  be  the  main  element  of  the  disease.  Evidences  of 
more  or  less  peritonitis  are  very  general.  In  the  more  severe  cases  there 
is  little  or  no  exudation  of  plastic  lymph,  such  as  is  found  in  peritonitis 
unassociated  with  septiceemia.  There  is  a  greater  or  less  quantity  of 
brownish  serum  only,  the  coils  of  intestine,  distended  with  flatus  and 
highly  congested,  being  surrounded  by  it.  More  often  there  are  patchy 
deposits  of  fibrinous  exudation  over  many  of  the  viscera,  the  fundus 
uteri,  the  under  surface  of  the  liver,  and  the  distended  intestines.  There 
is  then  also  a  considerable  quantity  of  sero-purulent  fluid  in  the  abdom- 
inal cavity.  The  pleural  cavities  may  also  exhibit  similar  traces  of 
inflammatory  action,  containing  imperfectly-organized  lympth  and  sero- 
purulent  fluid.  Schroeder  states  that  pleurisy  is  more  often  the  direct 
result  of  transmission  of  inflammation  through  the  substance  of  the  dia- 
phragm or  lung  than  a  secondary  consequence  of  the  septicaemia.  In 
like  manner,  evidences  of  pericarditis  may  exist,  the  surface  of  the  peri- 
cardium being  highly  injected  and  its  cavity  containing  serous  fluid. 
Inflammation  of  the  synovial  membranes  of  the  larger  joints,  occasion- 
ally ending  in  suppuration,  is  not  uncommon,  and  may  probably  be  best 
included  under  this  .class  of  cases. 

Cases  characterized  by  Changes  in  the  Mucous  Membranes. — In  the 
third  type  the  mucous  membranes  appear  to  bear  the  brunt  of  the  dis- 
ease. The  pathological  changes  are  most  marked  in  the  mucous  mem- 
brane lining  the  intestines,  which  is  highly  congested,  and  even  ulcerated 
in  patches,  with  numerous  small  spots  of  blood  extravasated  in  the  sub- 
mucous tissue.  Similar  small  apoplectic  effusions  have  been  observed 
in  the  substance  of  the  kidneys  and  under  the  mucous  membrane  of  the 
bladder.  Pneumonia  is  of  common  occurrence.  In  most  cases  it  is 
probably  secondary  to  the  impaction  of  minute  emboli  in  the  smaller 
branches  of  the  pulmonary  artery,  but  it  may  doubtless  arise  from  inde- 
pendent inflammation  of  the  lung-tissue,  and  will  then  be  included  in 
the  class  of  cases   now  under  consideration. 

Cases  characterized  by  the  Impaction  of  Infected  Emboli  and  Second- 
ary Inflammation  and  Abscess. — The  fourth  class  of  pathological  phe- 
nomena are  those  which  are  produced  chiefly  by  the  impaction  of  minute 
infected  emboli  in  small  vessels  in  various  parts  of  the  body.  These 
are  the  cases  which  most  closely  resemble  surgical  pyemia,  both  in  their 
symptoms  and  post-mortem  signs,  and  which  by  many  writers  are 
described  under  the  name  of  puerperal  pyaemia.  The  dependence  of 
puerperal  fever  on  phlebitis  of  the  uterine  veins  was  a  favorite  theory, 
and  in  a  large  proportion  of  cases  the  coats  of  the  veins  show  signs  of 
inflammation,  their  canals  being  occupied  with  thrombi  in  a  more  or 
less  advanced  state  of  disintegration.  The  mode  in  which  these  thrombi 
may  become  infected  has  been  shown  by  Babnoff,  who  has  proved  that 
leucocytes  may  penetrate  the  coats  of  the  vein,  and,  entering  its  con- 
tained  coagulum,  may  set  up  disintegration  and  suppuration.      This 


PUEBPERA  L  SEPTICAEMIA. 


609 


observation  brings  these  pyaemic  forms  of  disease  into  close  relation  with 
septicsemia,  such  as  we  have  been  studying,  and  justifies  the  conclusion 
of  Verneuil  that  purulent  infection  is  not  a  distinct  disease,  but  only  a 
termination  of  septicaemia,  with  which  it  ought  to  be  studied.  We  have, 
moreover,  to  differentiate  these  re.sults  of  embolism  from  those  considered 
in  a  subsequent  chapter,  the  characteristic  of  these  cases  being  the  infected 
nature  of  the  minute  emboli.  Localized  inflammations  and  abscesses 
from  the  impaction  of  minute  capillary  emboli  are  found  in  many  parts 
of  the  body — most  frequently  in  the  lungs,  then  in  the  kidneys,  spleen, 
and  liver,  and  also  in  the  muscles  and  connective  tissues.  Pathologists 
are  by  no  means  agreed  as  to  the  invariable  dependence  of  these  on 
embolism,  nor  is  it  possible  to  prove  their  origin  from  this  source  by 
post-mortem  examination.  Some  attribute  all  such  cases  to  embolism ; 
others  think  that  they  may  be  the  results  of  primary  septicemic  inflam- 
mation. It  has  been  proved  by  Weber  that  minute  infected  emboli  may 
pass  through  the  lung  capillaries ;  and  this  disposes  of  one  argument 
against  the  embolic  theory  based  on  the  supposed  impossibility  of  their 
passage.  It  is  probable  that  both  causes  may  operate,  and  that  localized 
inflammations  occurring  a  short  time  after  delivery  are  directly  produced 

Fig.  193. 


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by  the  infected  blood,  while  tlio.se  o(!(nirring  after  the  lapse  of  some  time, 
as  in  the  second  or  third  week,  de[)end  upon  embolism. 

DcACTiption  of  the  DiHe/iHc. — From  what  has  been  said  as  to  the  mode 
of  infection  in  puerperal  Kej)ti(!a3nn*a,  and  as  to  the  very  various  ]>atho- 
logical  changes  which  accompany  it,  it  will  not  be  a  matter  oi'  surpri.sc 

39 


610 


THE  PUERPERAL  STATE. 


to  find  that  the  symptoms  are  also  very  various  in  different  cases.  This 
can  readily  be  explained  by  the  amount  and  virulence  of  the  poison 
absorbed,  the  channels  of  infection,  and  the  organs  which  are  chiefly 
implicated ;  but  it  renders  it  very  difficult  to  describe  the  disease  satis- 
factorily. 

The  symptoms  generally  show  themselves  within  two  or  three  days 
after  delivery.  As  infection  most  often  occurs  during  labor,  or,  in  cases 
which  are  autogenetic,  within  a  short  time  afterward,  and  before  the 
lesions  of  continuity  in  the  generative  tract  have  commenced  to  cicatrize, 


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it  can  be  understood  why  septicaemia  rarely  commences  later  than  the 
fourth  or  fifth  day. 

The  Early  Symptoms  are  not  Well  Marked. — In  the  great  majority  of 
cases  the  disease  begins  insidiously.  There  are,  generally,  some  chilli- 
ness and  rigor,  but  by  no  means  always,  and  even  when  present  they 
frequently  escape  observation  or  are  referred  to  some  transient  cause. 
The  first  symptom  which  excites  attention  is  a  rise  in  the  pulse,  which 
may  vary  from  100  to  140  or  more,  according  to  the  severity  of  the 
attack  ;  and  the  thermometer  will  also  show  that  the  temperature  is  raised 
to  102°,  or  in  bad  cases  even  to  104°  or  106°.  Still,  it_  must  be  borne 
in  mind  that  both  the  pulse  and  temperature  may  be  increased  in  the 
puerperal  state  from  transient  causes,  and  do  not,  of  themselves,  justify 
the  diagnosis  of  septicemia. 


PUERPERAL  SEPTICEMIA. 


611 


Symptoms  of  Intense  Septiccemia. — In  the  more  intense  class  of  cases, 
in  which  the  whole  system  seems  overwhelmed  with  the  severity  of  the 
attack,  the  disease  progresses  with  great  rapidity  and  often  without  any 
appreciable  indication  of  local  complication.  The  pulse  is  very  rapid, 
small,  and  feeble,  varying  from  120  to  140,  and  there  is  generally  a 
temperature  of  103°  or  104°.  In  the  worst  form  of  cases  the  tempera- 
ture is  steadily  high,  without  marked  remissions.  (See  Figs.  193,  194, 
and  195.)  There  may  be  little  or  no  pain,  or  there  may  be  slight  ten- 
derness on  pressure  over  the  abdomen  or  uterus,  and  as  the  disease  pro- 
gresses the  intestines  get  largely  distended  with  flatus,  so  that  intense 
tympanites  often  form  a  most  distressing  symptom.  The  countenance  is 
sallow,  sunken,  and  has  a  very  anxious  expression.  As  a  rule,  intelli- 
gence is  unimpaired,  and  this  may  be  the  case  even  in  the  worst  forms 
of  the  disease  and  up  to  the  period  of  death.  At  other  times  there  is 
a  good  deal  of  low  muttering  delirium,  which  often  occurs  at  night 
alone,  and  alternates  with  intervals  of  complete  consciousness,  but  is 
occasionally  intensified  for  a  short  time  into  a  more  acute  form.  Diar- 
rhoea and  vomiting  are  of  very  frequent  occurrence ;  by  the  latter  dark, 
grumous,  coffee-ground  substances  are  ejected.     The  diarrhoea  is  occa- 

FiG.  ]95. 


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sionally  very  profuse  and  uncontro]]al)lc  ;  in  mild  cascss  it  seems  to  relieve 
the  severity  of  the  .symptoms,     Tiie  tongue  is  moist  and   loa<lcd  with     "-X-^^^ 
sordes,  but  sometimes  it  gets  dark  and  dry,  csjx'cially  toward  the  termi- 
nation of  the  disca.sc.     The  lochia  arc  generally  sn|)|)rc.ssc(l  or  altered  in 
character,  and  .sometimes  they  have  a  highly  offensive  odor,  especially 


612 


THE  PUERPERAL  STATE. 


when  the  disease  is  autogenetic.  The  breathing  is  hurried  and  panting, 
and  the  breath  itself  has  a  very  characteristic,  heavy,  sweetish  odor. 
The  secretion  of  milk  is  often,  but  not  always,  arrested. 

Duration  of  the  Disease. — With  more  or  less  of  these  symptoms  the 
case  goes  on,  and  when  it  ends  fatally  it  generally  does  so  within  a  week, 
the  fatal  termination  being  indicated  by  more  weakness,  rapid,  thread- 
like, or  intermittent  pulse,  marked  delirium,  great  tympanites,  and  some- 
times a  sudden  fall  of  temperature,  until  at  last  the  patient  sinks  with 
all  the  symptoms  of  profound  exhaustion. 

Variety  of  Symptoms  in  Different  Cases. — In  milder  cases  similar 
symptoms,  variously  modified  and  combined,  are  present.     It  is  seldom 

Fig.  196. 


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DAY  OF 
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4th. 

5TH. 

6th. 

7TH. 

8th. 

9TH. 

10TH 

11TH 

12TH. 

13TH 

14TH 

PULSE 

102 

88 

100 

108 

DATE 

2 

3 

4 

5 

^ 

' 

8 

9 

10 

11 

12 

13 

14 

15 

that  two  precisely  similar  cases  are  met  with ;  in  some  the  rapid  weak 
pulse  is  most  marked ;  in  others,  abdominal  distension,  vomiting,  diar- 
rhoea, or  delirium. 

Symptoms  of  Peritonitis. — Local  complications  variously  modify  +he 
symptoms  and  course  of  the  disease.  The  most  common  is  perito' -itis, 
so  much  so  that  with  some  authors  puerperal  fever  and  puerperal  peri- 
tonitis are  synonymous  terms.  Here  the  first  symptom  is  severe  abdomi- 
nal pain,  commencing  at  the  lower  part  of  the  abdomen,  wdiere  the 
uterus  is  felt  enlarged  and  tender.  As  the  abdominal  pain  and  tender- 
ness spread,  the  sufferings  of  the  patient  greatly  increase,  the  intestines 
become  enormously  distended  with  flatus,  and  the  breathing  is  entirely 


PUERPERAL  SEPTICEMIA. 


613 


thoracic  in  consequence  of  the  upward  displacement  of  the  diaphragm 
and  the  fact  that  the  abdominal  muscles  are  instinctively  kept  as  much 
in  repose  as  possible.  The  patient  lies  on  her  back  with  her  knees  drawn 
up,  and  sometimes  cannot  bear  the  slightest  pressure  of  the  bed-clothes. 
There  is  generally  much  vomiting,  and  often  severe  diarrhoea.  The 
temperature  generally  ranges  from  102°  to  104°,  or  even  106°,  and  is 
subject  to  occasional  exacerbations  and  remissions,  possibly  depending 
on  fresh  absorption  of  septic  matter.  (See  Temperature  charts,  Figs. 
196,  197,  and  198.)    The  case  generally  lasts  for  a  week  or  more,  the 

Fia.  197. 


TIME 

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DAY  OF 
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2N0. 

3RD. 

4TM. 

6TH. 

6TH. 

7TH, 

8TH. 

9TH- 

10TH, 

11th. 

12TH. 

13th 

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17TH, 

PULSE 

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DATE 

26 

27 

28 

29 

30 

31 

Augl 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

symptoms  going  on  from  bad  to  worse  and  the  patient  dying  exhaust- 
erl.  D'Espine  points  out  that  rigors,  with  exacerbations  of  the  general 
.symptoms,  not  unfrequently  occur  about  the  sixth  or  seventh  day,  Avhich 
he  attributes  to  fresh  systemic  infection  from  fetid  pus  in  the  peritoneal 
cavity.  It  must  not  be  supposed  that  all  these  symptoms  are  necessarily 
present  when  the  peritonitic  complication  exists.  Pain  especially  is  often 
entirely  aljsent,  and  I  have  seen  cases  in  Avhich  post-mortem  examina- 
tion proved  the  existence  of  peritonitis  in  a  very  marked  degree,  in 
which  puin  was  entirely  absent.  Sometimes  the  pain  is  only  slight,  and 
amounts  to  little  more  than  tenderness  over  the  uterus. 

Symjjf.oms  of  other  Local  Complications. — Symptoms  of  other  local 
complications  are  characterized  by  their  own  sjiecial  symjitoms ;  thus, 
pneumonia  by  dyspna-a,  cough,  dnltiess,  etc.;    pericarditis  by  the  cha- 


614 


THE  PUERPERAL  STATE. 


racteristic  rub ;  pleurisy  by  dulness  on  percussion ;  kidney  affection  by 
albuminuria  and  the  presence  of  casts ;  liver  complication  by  jaundice  ; 

and  so  on. 

Fycemic  Forms  of  the  Disease. — The  course  of  the  disease  is  not 
always  so  intense  and  rapid,  being  in  some  cases  of  a  more  chronic  cha- 


FiG.  198. 


TIME 

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M 

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M|E 

M 

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M   E 

M  E 

M 

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M 

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M 

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M    F 

m|e 

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M   E 

MJE 

1 

107° 

lob 

I0S° 

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103 
'? 

I     102 

z 

3             o 
<     100 

E             , 

NORM.  TEM 
OF  BODY 

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PULSE 

84 

96 

84 

116 

96 

120 

88 

78 

DATE 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

racter  and  lasting;  many  weeks.  The  symptoms  in  the  early  stage  are 
often  indistinguishable  from  those  already  described,  and  it  is  generally 
only  after  the  second  Aveek  that  indications  of  purulent  infection  develop 
themselves.  Then  we  often  have  recurrent  and  very  severe  rigors,  with 
marked  elevations  and  remissions  of  temperature.  At  the  same  time 
there  is  generally  an  exacerbation  of  the  general  symptoms,  a  peculiar 
yellowish  discoloration  of  the  skin,  and  occasionally  well-developed 
jaundice.  Transient  patches  of  erythema  are  not  uncommonly  observed 
on  various  parts  of  the  skin,  and  such  eruptions  have  often  been  mis- 
taken for  those  of  scarlet  fever  or  other  zymotic  disease.  Localized 
inflammations  and  suppuration  may  rapidly  follow.  Amongst  the 
most  common  is  inflammation  or  even  suppuration  of  the  joints — the 
knees,  shoulders,  or  hips — which  Is  preceded  by  difficulty  of  movement, 
swelling,  and  very  acute  pain.  Large  collections  of  pus  in  various  parts 
of  the  muscles  and  conective  tissues  are  not  rare.  Suppurative  inflam- 
mation may  also  be  found  in  connection  with  many  organs,  as  in  the 
eye,  in  the  pleura,  pericardium,  or  lungs  ;  each  of  which  will,  of  course. 


PUEBPEBAL  8EPTICMMIA.  615 

give  rise  to  characteristic  symptoms,  more  or  less  modified  by  the  type 
of  the  disease  and  the  intensity  of  the  inflammation. 

Puerperal  Malarial  Fever. — There  is  a  peculiar  form  of  febrile  dis- 
turbance which  sometimes  occurs  in  the  puerperal  state,  and  which  is 
apt  to  be  confounded  with  septicaemia,  to  which  attention  has  been  speci- 
ally, directed  by  Fordyce  Barker  ^  under  the  name  of  "  puerperal  mala- 
rial fever."  It  is  specially  apt  to  be  met  with  in  women  who  have  been 
exposed  to  malarial  poison  during  their  former  lives,  the  recurrence  of 
the  fever  being  probably  determined  by  the  puerperal  state.  Of  this  I 
have  seen  several  very  well-marked  examples  in  ladies  who  have  for- 
merly contracted  fever  or  ague  in  India.  One  of  my  patients,  who  has 
long  been  in  India  and  suifered  from  intermittent  fever  for  years,  is 
invariably  attacked  with  it  after  delivery,  and  herself  warned  me  of  the 
fact  the  first  time  I  attended  her.  The  diagnosis  is  not  always  easy. 
Barker  insists  on  the  fact  that  puerperal  malarial  fever  generally  com- 
mences after  the  fifth  day  from  delivery,  while  septicaemia  almost  always 
does  so  before  that  time.  In  the  malarial  fever,  moreover,  the  intermis-i 
sions  are  much  more  marked,  while  there  are  frequently-recurring  chills i 
or  rigors,  which  is  not  the  case  in  septicsemia. 

Treatment. — In  considering  the  all-important  subject  of  treatment  the 
views  of  the  practitioner  are  naturally  biassed  by  the  theory  he  has 
adopted  of  the  nature  of  the  disease.  If  that  here  inculcated  be  correct, 
the  indications  we  have  to  bear  in  mind  are — 1st,  to  discover,  if  possible, 
the  source  of  the  poison,  in  the  hope  of  arresting  further  septic  absorp- 
tion ;  2d,  to  keep  the  patient  alive  until  the  effects  of  the  poison  are  i 
worn  ofP;  and,  3d,  to  treat  any  local  complications  that  may  arise.       / 

The  Use  of  Antiseptic  Injections. — The  first  is  likely  to  be  of  great' 
importance  in  cases  of  self-infection,  as  fresh  quantities  of  septic  matter 
may  be  from  time  to  time  absorbed.  We,  fortunately,  are  in  possession 
of  a  powerful  means  of  preventing  further  absorption  by  the  applica- 
tion of  antiseptics  to  the  interior  of  the  uterus  and  to  the  canal  of  the 
vagina.^  This  is  especially  valuable  when  the  existence  of  decomposing 
coagula  or  other  sources  of  septic  matter  is  suspected  in  the  uterine 
cavity,  or  when  offensive  discharges  are  present.     Disinfection  is  readily 

^  "Puerperal  Malarial  Fever,"  Amer.  Jonrn.  of  Obstet.,  April,  1880. 
^  My  colleague.  Dr.  Hayes,  has  invented  a  silver  tube  for  the  purpose  of  administering 
such  intra-uterine  injections  (Fig.  199),  which  answers  its  purpose  admirably.     The 

Fig.  199. 


Iliiycs's  'I'lilic  Cor  liitra,-nl,en'ne  Tnju(!tion.'^. 

numerous  apertures  at  its  extremity  allow  of  a  number  of  minute  streams  of  fluid 
being  tlirown  o\it  in  the  form  of  a  spray  over  the  interior  of  the  uterus,  tlie  complete 
bathing  of  its  surface  and  washing  out  of  its  cavity  being  thus  ensured.  It  is,  more- 
over, introd\iced  more  easily  tlian  tiie  ordinary  vaginal  pipe,  and  can  be  attaciied  to  a 
Higginson  syringe. 


616 


THE  PUERPERAL  STATE. 


Fig.  200 . 


107- 

I06' 

los' 

-1 

<   104" 

0 

0    '"-^ 

W-  f 

*': 

EM 

I 

t 

L 

M 

E 

V 

1 

M 

E 

E 
> 

M 

E 

M 

E 

M 

t 

^. 

• 

z   101 

k. 

99 

A 

- 

J 

f 

\ 

^ 

•v 

/■ 

/ 

/ 

11 

K 

/ 

■-. 

DafefDU 

I" 

2- 

V^ 

4" 

S" 

.    <>" 

7" 

8 

'■ 

90. 

-i-N 

Fig.  201. 


accomplished  by  washing  out  the  uterine  cavity  at  least  twice  daily  by 
means  of  a  Higginson's  syringe  with  a  long  vaginal  pipe  attached.     The 

results  are  sometimes  very  remai'kable, 
the  threatening  symptoms  rapidly  disap- 
pearing, and  the  temperature  and  pulse 
tailing  so  soon  after  the  use  of  the  anti- 
septic injections  as  to  leave  no  doubt  of 
the  beneficial  eifects  of  the  treatment. 
I  cannot  better  illustrate  the  advantages 
of  this  treatment  than  by  this  tempera- 
ture chart  (Fig.  200),  which  is  from  a  case 
which    came   under  my   observation  in 
the  out-door  practice  of  King's  College 
Hospital.      It  was  that   of  a  healthy 
woman,    thirty-six  years    of   age,  who 
had  an  easy  and  natural  labor.     Noth- 
ing remarkable  Mas  observed  until  the 
third  day  after  delivery,  when  the  temperature  was  found  to  be  slightly 
increased.     On  the  morning  of  the  eighth  day  the  temperature  had  risen 
to  105.8°.     She  was  delirious,  with  a  rapid,  thready  pulse,  clammy  per- 
spiration, tympanitic  abdomen,  and  her 
general  condition  indicated  the  most  ur- 
gent danger.     On  vaginal  examination 
a  piece  of  compressed  and  putrid  pla- 
centa was  found  in  the  os.     This  was 
removed  by  my  colleague.  Dr.  Hayes, 
and  the  uterus  thoroughly  washed  out 
w^ith    Condy's  fluid   and    water.     The 
same  evening  the  temj^erature  had  sunk 
to  99°,  and  the  general  symptoms  were 
much  improved.  The  next  day  there  was 
a  slight  return  of  oifensive  discharge 
and  an  aggravation  of  the  symptoms. 
After  again  washing  out  the  uterus  the 
temperature  fell,   and    from  that    date 
the  patient  convalesced  without  a  single 
bad  symj)tom  (Fig.  201). 

This  is  a  very  well-marked  example 
of  the  value  of  local  antiseptic  treat- 
ment, and  I  have  seen  many  cases  of 
the  same  kind.  It  should  therefore 
never  be  omitted  in  all  cases  in  which 
self-infection  is  possible ;  and,  indeed, 
even  when  there  is  no  reason  to  suspect 
the  presence  of  a  local  focus  of  infec- 
tion the  use  of  antiseptic  lotions  is  ad- 
visable as  a  matter  of  precaution,  since 
it  can  do  no  harm  and  is  generally  com- 
forting to  the  patient.  Any  antiseptic  may  be  used,  such  as  a  weak  solu- 
tion of  carbolic  acid,  1  in  50,  or  of  tincture  of  iodine,  or  Condy's  fluid 


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DATE 

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28 

PUERPERAL  SEPTICEMIA.        .  617 

largely  diluted.  I  generally  use  the  two  latter  alternately,  the  one  in 
the  morning,  the  other  in  the  evening.  Occasionally  I  have  employed  a 
l-in-50  solution  of  carbolic  acid,  with  about  5  grains  to  the  ounce  of 
iodoform  suspended  in  it.  This  has  the  advantage  of  not  only  being  a 
very  powerful  antiseptic,  but  of  acting  more  continuously  in  consequence 
of  the  powdered  iodoform  remaining  partially  attached  to  the  uterine 
walls ;  or,  as  some  have  advised,  an  iodoform  pessary  may  be  placed 
in  the  uterine  cavity.  The  nozzle  of  the  syringe  should  be  guided  well 
through  the  cervix,  and  the  cavity  of  the  uterus  thoroughly  washed 
out  until  the  fluid  that  issues  from  the  vagina  is  no  longer  discolored. 
As  the  OS  is  always  patulous,  there  is  no  risk  of  producing  the  trouble- 
some symptoms  of  uterine  colic  which  occasionally  follow  the  use  of 
intra-uterine  injections  in  the  unimpregnated  state.  It  is  quite  useless 
to  entrust  the  injection  to  the  nurse,  and  it  should  be  performed  at  least 
twice  daily  by  the  practitioner  himself  in  all  cases  in  which  the  dis- 
charges are  offensive.  It  is  not  advisable,  however,  that  such  injections 
should  be  used  indiscriminately,  since  they  are  not  entirely  free  from 
risk,  nor  should  they  be  continued  for  more  than  a  few  days.  The  vulva 
should  in  all  cases  be  carefully  inspected,  with  the  view  of  ascertaining 
if  the  source  of  infection  be  not  some  local  slough  or  necrotic  ulcer  about 
the  perineum  or  orifice  of  the  vagina,  in  which  case  its  surface  should  be 
freely  covered  with  iodoform.  I  have  seen  more  than  one  instance  in 
which  this  simple  procedure  has  sufficed  to  cut  short  symptoms  of  a  very 
threatening  character. 

Administration  of  Food  and  Stimulants. — In  a  disease  characterized 
by  so  marked  a  tendency  to  prostration  the  importance  of  sustaining 
the  vital  powers  by  an  abundance  of  easily-assimilated  nourishment 
cannot  be  overrated.  Strong  beef-tea  or  other  forms  of  animal  soup, 
milk,  alone  or  mixed  either  with  lime-  or  soda-water,  and  the  yelk  of 
eggs  beat  up  with  milk  and  brandy,  should  be  given  at  short  intervals, 
and  in  as  large  quantities  as  the  patient  can  be  induced  to  take ;  and  the 
value  of  thoroughly  efficient  nursing  will  he  especially  apparent  in  the 
management  of  this  important  part  of  the  treatment.  As  there  is  fre- 
quently a  tendency  to  nausea,  the  patient  may  resist  the  administration 
of  food,  and  the  resources  of  the  practitioner  will  be  taxed  in  adminis- 
tering it  in  such  form  and  variety  as  will  prove  least  distasteful.  Gen- 
erally speaking,  not  more  than  one  or  two  hours  should  be  allowed  to 
elapse  without  some  nutriment  being  given.  The  amount  of  stimulant 
refjuired  will  vary  with  the  intensity  of  the  symptoms  and  the  indica- 
tions of  debility.  Generally,  stimulants  are  well  borne,  prove  decidedly 
beneficial,  and  require  to  be  given  pretty  freely.  In  cases  of  moderate 
severity  a  taljlespoonful  of  good  old  brandy  or  whiskey  every  four  liours 
may  suffice ;  but  when  the  pulse  is  very  rapid  and  thready,  Avhcn  there 
is  much  low  delirium,  tyjnpanites,  or  sweating  (indicating  profound 
exhaustion),  it  may  be  advisable  to  give  them  h\  much  larger  quantities 
and  at  shorter  intervals.  The  careful  practitioner  will  closely  Avatch  the 
elT'ects  produced,  and  regidate  the  amount  by  the  state  of  the  j)atient, 
rather  than  ])y  any  fixed  rule ;  but  in  severe  cases  eight  or  twelve 
ounces  of  brandy,  or  even  more,  in  the  twenty-four  hours  may  be  given 
with  decided  benefit. 


618  THE  PUEBPERAL  STATE. 

Venesection  not  Admissable. — Venesection,  both  general  and  local,  was 
long  considered  a  sheet-anchor  in  this  disease.  Modern  views  are,  how- 
ever, entirely  opposed  to  its  use ;  and  in  a  disease  characterized  by  so 
profound  an  alteration  of  the  blood  and  so  much  prostration  it  is  too 
dangerous  a  remedy  to  employ,  although  it  is  possible  that  it  might  alle- 
viate temporarily  the  severity  of  some  of  the  symptoms,  especially  in 
cases  in  which  peritonitis  is  well  marked  and  much  local  pain  and  ten- 
derness are  present.  ['] 

Medicinal  Trecdment. — The  rational  indications  in  medicinal  treatment 
are  to  lessen  the  force  of  the  circulation  as  much  as  is  possible  without 
favoring  exhaustion,  and  to  diminish  the  temperature. 

Use  of  Artericd  Sedatives. — For  the  former  purpose  Barker  strongly 
advocates  the  use  of  veratrum  viride,  in  doses  of  five  drops  of  the  tinc- 
ture every  hour,  until  the  pulse  falls  to  below  100,  when  its  effects  are 
subsequently  kept  up  by  two  or  three  drops  every  second  hour.  Of  this 
drug  I  have  no  personal  experience,  but  I  have  extensively  used  minute 
doses  of  tincture  of  aconite  for  the  same  purpose,  and  when  carefully 
given  I  believe  it  to  be  a  most  valuable  remedy.  The  way  I  have 
administered  it  is  to  give  a  single  drop  of  the  tincture,  at  first  every 
half  hour,  increasing  the  interval  of  administration  according  to  the 
effect  produced.  Generally,  after  giving  four  or  five  doses  at  intervals 
of  half  an  hour,  the  pulse  begins  to  fall,  and  afterward  a  few  doses,  at 
intervals  of  one  or  two  hours,  will  suffice  to  prevent  the  heart's  action 
rising  to  its  former  rapidity.  The  advantage  of  thus  modifying  cardiac 
action  with  the  view  of  preventing  excessive  waste  of  tissue  cannot  be 
questioned.  It  is  evident  that  so  powerful  a  remedy  must  not  be  used 
without  the  most  careful  supervision,  for,  if  continued  too  long  or  given 
at  too  frequent  intervals,  it  may  unduly  depress  the  circulation,  and  do 
more  harm  than  good.  It  is  necessary,  therefore,  that  the  practitioner 
should  constantly  watch  the  effect  of  the  drug,  and  stop  it  if  the  pulse 
become  very  weak  or  if  it  intermit.  It  is  most  likely  to  be  useful  at  an 
early  stage  of  the  disease  before  much  exhaustion  is  present,  and  then 
only  M'hen  the  pulse  is  of  a  certain  force  and  volume.  Barker  says  of 
the  veratrum  viride,  what  is  also  true  of  aconite,  that  "  it  should  not  be 
given  in  those  cases  in  which  rapid  prostration  is  manifested  by  a  feeble, 
thread-like,  irregular  pulse,  profuse  sweats,  and  cold  extremities." 

Reduction  of  Temperature. — The  reduction  of  temperature  must  form 
an  important  part  of  our  treatment,  and  for  this  purpose  many  agents 
are  at  our  disposal. 

Quinine. — Quinine  in  large  doses,  of  from  10  to  30  grains,  has  been 
much  used  for  this  purpose,  especially  in  Germany.   After  its  exhibition 

\}  I  believe  that  the  entire  abandonment  of  venesection  has  been  a  grave  error,  and 
that  wliere  there  is  early  in  the  attack  a  high  pulse,  with  great  abdominal  distension 
and  tenderness  and  a  decided  elevation  of  temperature,  we  ought  to  bleed  the  [)atient, 
sitting,  at  once,  and  to  such  ti  degree  as  to  produce  a  decided  impression.  One  of  the 
worst  cases  I  ever  saw  was  cured  in  this  way.  The  woman  was  delivered  at  oh  P.  M. 
of  one  day,  and  the  disease  manifested  itself  in  twenty  hours.  At  9  the  next  morning 
she  was  apparently  doing  well ;  at  1  she  was  in  great  sviffering,  and  could  not  bear  her 
abdomen  to  be  touched  ;  vs.  f  ,^x\'j  :  at  9  p.  M.,  symptoms  more  grave  ;  vs.  f  ,5x1  in  a  sit- 
ting posture  until  she  felt  sick.  At  10  p.m.  pulse  150:  in  twenty-four  hours  from  this 
no  fever  and  very  little  pain:  in  three  days  regarded  as  out  of  danger.  Saw  her  in 
robust  health,  with  her  child  living,  a  year  later. — Ed.] 


PUERPERAL  SEPTICEMIA.  619 

the  temperature  frequently  falls  one  or  two  degrees.  It  may  be  given 
morning  and  evening.  Unpleasant  head-symptoms,  deafness,  and  ring- 
ing in  the  ears  often  render  its  continuance  for  a  length  of  time  impossi- 
ble. These  may,  however,  be  much  lessened  by  the  addition  of  10  to  15 
minims  of  hydrobromic  acid  to  each  dose. 

Salicylic  Acid. — Salicylic  acid,  in  doses  of  from  10  to  20  grains,  or 
the  salicylate  of  soda  in  the  same  doses,  is  a  valuable  antipyretic  which 
I  have  found  on  the  wdiole  more  manageable  than  quinine.  Under  its 
use  the  temperature  often  falls  considerably  in  a  short  space  of  time.  It 
is,  however,  apt  to  depress  the  circulation,  and  thus  requires  to  be  care- 
fully watched  while  it  is  being  administered ;  and  should  the  pulse 
become  very  small  and  feeble  it  should  be  discontinued. 

Warburg's  Tincture. — In  some  cases,  especially  when  the  fever  has 
assumed  a  remittent  type,  I  have  administered  with  marked  benefit  a 
drug  which  is  of  high  repute  in  India  in  the  worst  class  of  malarious 
remittent  fevers,  and  the  almost  marvellous  effects  of  which  in  such 
cases  I  had  myself  witnessed  in  India  many  years  ago.  This  is  the 
so-called  "  Warburg's  tincture,"  the  value  of  which  has  been  testified 
to  by  many  high  authorities,  among  whom  I  may  mention  Dr.  Maclean 
of  Netley,  Dr.  Broadbent,  and  Sir  Alexander  Armstrong,  the  Director- 
General  of  the  Medical  Department  of  the  Navy,  who  informs  me  that  it 
is  now  supplied  to  all  Her  Majesty's  ships  in  the  tropics,  because  it  is  found 
to  be  of  the  utmost  value  in  cases  in  which  quinine  has  little  or  no  eifect. 

Recently  its  composition  has  been  made  public  by  Dr.  Maclean.  The 
basis  is  quinine,  in  combination  with  various  aromatics  and  bitters,  some 
of  which  probably  intensify  its  action.  Be  this  as  it  may,  the  testimony 
in  favor  of  the  antipyretic  action  of  the  remedy  is  very  strong.  I  have 
found  its  exhibition  followed  by  a  profuse  diaphoresis  (this  being  its 
almost  invariable  eifect),  and  sometimes  a  rapid  amelioration  of  the 
symptoms.  In  other  cases  in  which  I  have  tried  it,  like  everything  else, 
it  has  proved  of  no  avail.  Of  its  use  in  ten  malarial  cases  above  alluded 
to  Dr.  Fordyce  Barker  says  :  "  For  nearly  two  years  past,  in  those  cases 
where  the  stomach  will  tolerate  it,  I  have  found  Warburg's  tincture 
much  more  effective  and  speedy  in  producing  the  results  desired  than 
the  largest  doses  of  quinine."^ 

Application  of  Cold. — Cold  may  be  advantageously  tried  in  suitable 
cases.  The  simplest  mode  of  using  it  is  by  Thornton's  ice-cap,  by  which 
a  current  of  cold  water  is  kept  continuously  running  round  the  head. 
This  has  been  found  of  great  value  in  pyrexia  after  ovariotomy,  and  I 
have  also  found  it  useful  as  a  means  of  reducing  temperature  in  puer- 
peral cases.  It  is  a  comforting  application,  and  gives  great  relief  to  the 
throbbing  headache,  which  often  causes  much  suffering.  Under  its  use 
the  temperature  often  falls  two  or  more  degrees,  and  it  is  easily  continued 
day  and  night. 

In  very  serious  cases,  when  the  temperature  reaches  105°  and  upward, 
the  external  application  of  cold  to  the  rest  of  the  body  may  be  tried.  I 
have  elsewhere  related^  a  case  of  puerperal  septic£Bmia  with  hyper- 

^  Op.  ciL,  p.  278. 

*  "A  Lecture  on  a  Case  of  Puerperal  Septictemia,  with  Hyperpyrexia,  treated  by  the 
Continuous  Application  of  Cold,"  Brit.  Med  Journ.,  Nov.  17,  1877. 


620  THE  PUERPERAL  STATE. 

pyrexia,  the  temperature  continuously  ranging  over  105°,  in  which  I 
kept  tlie  patient  for  eleven  days  nearly  continuously  covered  with  cloths 
soaked  in  iced  water,  by  which  means  only  was  the  temperature  kept 
within  moderate  bounds  and  life  preserved.  But  this  method  of  treat- 
ment is  excessively  troublesome  and  is  in  no  way  curative.  It  is  only 
of  use  in  moderating  the  temperature  when  it  has  reached  a  point  at 
which  it  could  not  continue  long  without  destroying  the  patient.  I 
should  therefore  never  think  of  employing  it  unless  the  temperature  was 
over  105°,  and  then  only  as  a  temporary  expedient,  requiring  incessant 
watching,  to  be  desisted  from  as  soon  as  the  temperature  had  reached  a 
more  moderate  height.  It  is  clearly  impossible  to  place  a  puerperal 
patient  in  a  bath,  as  is  practised  in  hyperpyrexia  associated  with  acute 
rheumatism  or  typhoid  fever.  The  same  effect  may,  however,  be  obtained 
by  placing  her  on  macintosh  sheeting,  or,  still  better,  on  a  water-bed, 
into  which  cold  water  is  run  from  time  to  time,  and  covering  the  body 
with  towels  soaked  in  iced  water,  which  are  frequently  renewed  by  the 
attendant  nurses.  During  the  application  the  temperature  should  be 
constantly  taken,  and  as  soon  as  it  has  fallen  to  101°  the  cold  ajiplica- 
tions  should  be  discontinued. 

Administration  of  Turpentine. — Amongst  other  remedies  which  have 
been  used  is  turpentine,  which  was  highly  thought  of  by  the  Dublin 
school.  In  cases  with  much  tympanitic  distension  and  a  small  weak 
pulse  it  is  sometimes  of  unquestioname  value,  and  it  probably  acts  as  a 
strong  nervine  stimulant.  Given  in  doses  of  15  to  20  minims,  rubbed 
up  with  mucilage,  it  can  generally  be  taken  in  spite  of  its  nauseous 
taste. 

Evacuant  Remedies. — Purgatives,  diaphoretics,  or  even  emetics,  have 
often  been  employed  as  eliminants  of  the  poison.  The  former  are 
strongly  recommended  by  Schroeder  and  other  German  authorities,  and 
in  this  country  they  were  formerly  amongst  the  most  favorite  remedies, 
and  there  is  a  general  concurrence  of  opinion  amongst  our  older  writers 
as  to  their  value.  In  the  first  volume  of  the  Obstetrical  Journal  there 
is  a  paper  by  Mr.  Morton  in  which  this  practice  is  strongly  advocated, 
and  some  interesting  cases  are  recorded  in  which  it  apparently  acted 
Avell.  He  administers  calomel  in  closes  of  3  or  4  grains  with  compound 
extract  of  colocynth,  so  as  to  keep  up  a  free  action  of  the  bowels.  It 
seems  quite  reasonable,  when  there  is  constipation,  to  promote  a  gentle 
action  of  the  boM'els  by  some  mild  aperient ;  but,  bearing  in  mind  that 
severe  and  exhausting  diarrhoea  is  a  common  accompaniment  of  the  dis- 
ease, I  should  myself  hesitate  to  run  the  risk  of  inducing  it  artificially, 
especially  as  there  is  no  proof  whatever  that  septic  matter  can  really  be 
eliminated  in  this  way.  At  the  commencement  of  the  disease,  however, 
I  have  often  given  one  or  two  aperient  doses  of  calomel  with  decided 
benefit. 

Internal  Antiseptic  Remedies. — It  is  possible  that  further  research  will 
give  us  some  means  of  counteracting  the  septic  state  of  the  blood ;  and 
the  sulphites  and  carbolates  have  been  given  for  this  purjjose,  but  as  yet 
with  no  reliable  results. 

Tincture  of  Perchloride  of  Iron. — The  tincture  of  the  perchloride  of 
iron  naturally  suggests  itself  from  its  well-known  effects  in  surgical 


PUEBPEBAL   VENOUS  THBOMBOSIS  AND  EMBOLISM.        621 

pysemia.  In  the  less  intense  forms  of  the  disease,  especially  when  local 
suppurations  exist,  it  is  certainly  useful,  and  may  be  given  in  doses  of 
10  to  20  minims  every  three  or  four  hours.  In  very  acute  cases  other 
remedies  are  more  reliable,  and  the  iron  has  the  disadvantage  of  not 
unfrequently  causing  nausea  or  vomiting. 

Opiates. — When  restlessness,  irritation,  and  want  of  sleep  are  promi- 
nent symptoms,  sedatives  may  be  required.  Under  such  circumstances 
opiates  may  be  given  at  night,  and  Battley's  solution,  nepenthe,  or  the 
hypodermic  injection  of  morphia  are  the  forms  which  answer  best. 

Treatment  of  Local  Complications. — Pain  and  tenderness  and  local 
complications  must  be  treated  on  general  principles.  The  distress  from 
them  is  most  experienced  when  peritonitis  is  well  marked.  Then  warm 
and  moist  applications,  in  the  form  of  poultices  or  fomentations,  are  very 
useful.  Relief  is  also  sometimes  obtained  from  turpentine  stupes,  and 
when  the  tympanites  is  distressing  turpentine  enemata  are  very  service- 
able. I  have  found  the  free  application  over  the  abdomen  of  the  flexi- 
ble collodium  of  the  Pharmacopoeia  decidedly  useful  in  alleviating  the 
suffering  from  peritonitis. 

Such  are  the  remedies  most  used  in  this  disease.  It  is  needless  to  say 
that  it  is  quite  impossible  to  lay  down  fixed  rules  for  the  management 
of  any  individual  case ;  and  it  is  obvious  that  if  puerperal  septicsemia  be 
not  a  special  and  distinct  disease,  its  judicious  treatment  must  depend  on 
the  general  knowledge  of  the  attendant  and  on  a  careful  study  of  the 
symptoms  each  separate  case  presents. 


CHAPTER  VI. 

PUERPEEAL  VENOUS  THROMBOSIS  AND  EMBOLISM. 

Puerperal  Thrombosis,  and  its  Mesults. — Under  the  head  of  thrombosis 
we  may  class  several  important  diseases  connected  with  the  puerperal 
state  which  have  received  far  less  attention  than  they  deserve.  It  is 
only  of  late  years  that  some — we  may  probably  safely  say  the  majority 
— of  those  terribly  sudden  deaths  which  from  time  to  time  occur  after 
deliveiy  have  been  traced  to  their  true  cause — viz.  obstruction  of  the 
right  side  of  the  heart  and  pulmonary  arteries  from  a  blood-clot,  either 
carried  from  a  distance  or,  as  I  shall  hope  to  show,  formed  in  situ. 
Although  the  result,  and,  to  a  great  extent,  the  symptoms,  are  identical 
in  both,  still  a  careful  consideration  of  the  history  of  these  two  classes 
of  cases  tends  to  show  that  in  their  causation  they  are  distinct  and  that 
they  cMight  not  to  be  confounded.  In  the  former  we  have  j)riiiiari]y  a 
clotting  of  blood  in  some  ])art  of  th(!  ])eri|)heral  venous  system,  and  the 
se])arati()n  of  a  ])ortion  of  sucli  a  thrombus  due  to  changes  undergone 
during  retrogradeinctainorpliosis  lending  to  its  eventual  nbs(tr])li()n.  In 
the  latter  we  have  a  local  deposition  of  fibrin,  the  result  of  blood-changes 


622  THE  PUERPERAL  STATE. 

consequent  on  pregnancy  and  the  puerperal  state.  The  formation  of 
such  a  coagulum  in  vessels  the  complete  obstruction  of  which  is  incom- 
patible with  life  explains  the  fatal  results.  When,  however,  a  coagulum 
chances  to  be  formed  in  more  distant  parts  of  the  circulation,  the  vital 
functions  are  not  immediately  interfered  with,  and  we  have  other  phe- 
nomena occurring  due  to  the  obstruction.  The  disease  known  as  phleg- 
masia dolens,  I  shall  presently  attempt  to  show,  is  one  result  of  blood- 
clot  forming  in  peripheral  vessels.  But  from  the  evident  and  tangible 
symptoms  it  produces  it  has  long  been  considered  an  essential  and  spe- 
cial disease,  and  the  general  blood-dyscrasia  which  produces  it,  as  well 
as  other  allied  states,  has  not  been  studied  separately.  I  shall  hope  to 
show  that  all  these  various  conditions,  dissimilar  as  they  at  first  sight 
appear,  are  very  closely  connected,  and  that  they  are  in  fact  due  to  a 
common  cause ;  and  thus,  I  think,  we  shall  arrive  at  a  clearer  and  more 
correct  idea  of  their  true  nature  than  if  we  looked  upon  them  as  distinct 
and  separate  affections,  as  has  been  commonly  done.  I  am  aware  that 
in  phlegmasia  dolens,  the  pathology  of  which  has  received  perhaps  more 
study  than  that  of  almost  any  other  puerperal  affection,  something 
beyond  simple  obstruction  of  the  venous  system  of  the  affected  limb  is 
probably  required  to  account  for  the  peculiar  tense  and  shining  swelling 
which  is  so  characteristic.  Whether  this  be  an  obstruction  of  the 
lymphatics,  as  Dr.  Tilbury  Fox  and  others  have  maintained  with  much 
show  of  reason,  or  whether  it  is  some  as  yet  undiscovered  state,  further 
investigation  is  required  to  show.  But  it  is  beyond  any  doubt  that  the 
imjjortant  and  essential  part  of  the  disease  is  the  presence  of  a  thrombus 
in  the  vessels ;  and  I  think  it  will  not  be  difficult  to  prove  that  in  its 
causation  and  history  it  is  precisely  similar  to  the  more  serious  cases  in 
which  the  pulmonary  arteries  are  involved. 

It  will  be  well  to  commence  the  study  of  the  subject  by  a  considera- 
tion of  the  conditions  which  in  the  puerperal  state  render  the  blood  so 
peculiarly  liable  to  coagulation,  and  we  may  then  proceed  to  discuss  the 
symptoms  and  results  of  the  formation  of  coagula  in  various  parts  of 
the  circulatory  system. 

Conditions  which  Favor  Thrombosis. — The  researches  of  Virchow, 
Benjamin  Ball,  Humphrey,  Richardson,  and  others  have  rendered  us 
tolerably  familiar  with  the  conditions  which  favor  the  coagulation  of  the 

1  blood  in  the  vessels.  These  are,  chiefly — 1.  A  stagnant  or  juirestedjcir- 
culation ;  as,  for  example,  when  the  blood  coagulates  in  the  veins  which 

I  (Jrawblood  from  the  gluteal  region  in  old  and  bedridden  people,  or  as 

I  in  some  forms  of  pulmonary  thrombosis,  in  wdiich  the  clots  in  the 
arteries  are  probably  the  result  of  obstruction  in  the  circulation  through 
the  lung-capillaries,  as  in  certain  cases  of  emphysema,  pneumonia,  or 
pulmonary  apoplexy.  2.  A  jiiechanical  obstruction  ^arouiid  which 
coagula^grm,  as  in  certain  morbid  states  of  the  vessels,  or,  a  better 

[example  still,  secondary  coagula  which  form  around  a  travelled  embolus 
impacted  in  the  pulmonary  arteries.  3.  And,  most  important  of  all,  in 
which  the  coagulatiqiwsJ;hej'esult  of  some  morbid  state  of  the  blgod 
itself.  Examples  of  this  last  condition  lire  frequently  met  with  in  the 
course  of  various  diseases,  such  as  rheumatism  or  fever,  in  which  the 
quantity  of  fibrin  is  increased  and  the  blood  itself  is  loaded  with  morbid 


PVEBPEBAL   VENOUS  THROMBOSIS  AND  EMBOLISM.        623 

material.  Thrombosis  from  this  cause  is  of  by  no  means  infrequent 
occurrence  after  severe  surgical  operations,  especially  such  as  have 
been  attended  with  much  hemorrhage,  or  when  the  patient  is  in  a 
weak  and  anaemic  condition.  This  has  been  specially  dwelt  upon  as 
a  not  infrequent  source  of  death  after  operation  by  Fayrer  and  other 
surgeons.^ 

Conditions  which  Favor  Coagulation  in  the  Puerperal  State. — But  little 
consideration  is  required  to  show  why  thrombosis  plays  so  important  a 
part  in  the  puerperal  state,  for  there  most  of  the  causes  favoring  its 
occurrence  are  present.  Probably  there  is  no  other  condition  in  which 
they  exist  in  so  marked  a  degree  or  are  so  frequently  combined.  The 
blood  contains  an  excess  of  fibrin,  which  largely  increases  in  the  latter 
months  of  utero-gestation,  until,  as  has  been  pointed  out  by  Andral  and 
Gavarret,  it  not  unfrequently  contains  a  third  more  than  the  average 
amount  present  in  the  non-pregnant  state.  As  soon  as  delivery  is  com- 
pleted other  causes  of  blood-dyscrasia  come  into  operation.  Involution 
of  the  largely  hypertrophied  uterus  commences,  and  the  blood  is  charged 
with  a  quantity  of  effete  material,  which  must  be  present,  in  greater  or 
less  amount,  until  that  process  is  completed.  It  is  an  old  observation 
that  phlegmasia  dolens  is  of  very  common  occurrence  in  patients  who 
have  lost  much  blood  during  labor.  Thus,  Dr.  Leishman  says  :  "  In 
no  class  of  cases  has  it  been  so  frequently  observed  as  in  women  whose 
strength  has  been  reduced  to  a  low  ebb  by  hemorrhage  either  during  or 
after  labor ;  and  this,  no  doubt,  accounts  for  the  observation  made  by 
Merriman,  that  it  is  relatively  a  common  occurrence  after  placenta  prse- 
via."  ^  An  examination  of  the  cases  in  which  death  results  from  pul- 
monary thrombosis  shows  the  same  facts,  as  in  a  large  proportion  of 
them  severe  post-partum  hemorrhage  has  occurred.  The  exhaustion 
following  the"  excessive  losses  so  common  after  labor  must  of  itself 
strongly  predispose  to  thrombosis,  and,  indeed,  loss  of  blood  has  been 
distinctly  ])ointed  out  by  Richardson  to  be  one  of  its  most  common  antece- 
dents. "  There  is,"  he  observes,  "  a  condition  which  has  been  long  known 
to  favor  coagulation  and  fibrinous  deposition.  I  mean  loss  of  blood  and 
syncope  or  exhaustion  during  impoverished  states  of  the  body." 

Since,  then,  so  many  of  the  predisposing  causes  of  thrombosis  are 
present  in  tlie  puerperal  state,  it  is  hardly  a  matter  of  astonishment  that 
it  should  be  of  frequent  occurrence  or  that  it  should  lead  to  conditions 
of  serious  gravity.  And  yet  the  attention  of  the  profession  has  been  for 
the  most  part  limited  to  a  study  of  one  only  of  the  results  of  this  tend- 
ency to  blood-clotting  after  delivery,  no  doubt  because  of  its  comjmrative 
frcfiuency  and  evident  symptoms.  True,  the  balance  of  professional 
opinion  lias  lately  held  that  ])hlegmasia  dolens  is  chiefly  the  result  of 
some  morbid  condition  of  tlie  blood,  producing  plugging  of  the  veins  ; 
but  the  wider  view  which  I  am  attempting  to  maintain,  which  would 
bring  this  disease  into  close  relation  with  the  more  rarely  observed  but 
indnitcly  ini|)ortant  obstructif)ns  ot'tlu;  ])ulm()nary  arteries,  has  scarcc^ly, 
if  at  all,  been  insisted  on.  Doubtless,  further  investigation  will  show 
that  it  is  not  in  these  parts  of  tlu;  venous  system  alone;  that  ])uerp('ral 

>  Edin.  Med.  Journ.,  March,  1801  ;   fndiMi  Annals  of  Med.,  July,  18G7. 
^  Lcislitnan,  Syntem  of  Obatetricif,  p.  710. 


624  THE  PUERPERAL  STATE. 

thrombosis  occurs,  but  the  symptoms  and  eiFects  of  venous  obstruction 
elsewhere,  important  though  they  may  be,  are  unknown. 

Distinction  between  Thrombosis  and  Embolism. — I  propose,  then,  to 
describe  the  symptoms  and  pathology  of  blood-clot  in  the  right  side  of 
the  heart  and  pulmonary  artery.  It  may  be  useful  here  to  re])eat  that 
this  is  essentially  distinct  from  embolism  of  the  same  parts.  The  latter 
is  obstruction  due  to  the  impaction  of  a  separated  portion  of  a  thrombus 
formed  elsewhere,  and  for  its  production  it  is  essential  that  thrombosis 
should  have  preceded  it.  Embolism  is,  in  fact,  an  accident  of  thrombo- 
^sis,  not  a  primary  affection.  The  condition  we  are  now  discussing  I  hold 
to  be  primary,  precisely  similar  in  its  causation  to  the  venous  obstruction 
which  in  other  situations  gives  rise  to  phlegmasia  dolens. 

Is  Primary  Thrombosis  in  the  Pulmonary  Arteries  Possible  f — At  the 
threshold  of  this  inquiry  we  have  to  meet  the  objection,  started  by 
several  who  have  written  on  this  subject,^  that  spontaneous  coagulation 
of  the  blood  in  the  right  side  of  the  heart  and  pulmonary  arteries  is 
a  mechanical  and  physiological  impossibility.  This  was  the  view  of 
Virchow,  who,  with  his  followers,  maintained  that  whenever  death  from 
pulmonary  obstruction  occurred  an  embolus  was  of  necessity  the  start- 
ing-point of  the  malady  and  the  nucleus  round  which  secondary  deposi- 
tion of  fibrin  took  place.  Virchow  holds  that  the  primary  factor  in 
thrombosis  is  a  stagnant  state  of  the  blood,  and  that  the  impulse  im- 
parted to  the  blood  by  the  right  ventricle  is  of  itself  sufficient  to  prevent 
coagulation.  It  is  to  be  observed  that  these  objections  are  purely  theo- 
retical. Without  denying  that  there  is  considerable  force  in  the  argu- 
ments adduced,  I  think  that  the  clinical  history  of  these  cases  strongly 
favors  the  view  of  spontaneous  coagulation  ;  and  I  would  apply  to  the 
theoretical  objections  advanced  the  argument  used  by  one  of  their 
strongest  upholders  with  regard  to  another  disputed  point :  "  Je  pr6- 
fere  laisser  la  parole  aux  faits,  car  devant  eux  la  theorie  s'incline."^ 

The  anatomical  arrangement  of  the  pulmonary  arteries  shows  how 
spontaneous  coagulation  may  be  favored  in  them ;  for,  as  Dr.  Humphry 
has  pointed  out,^  "  the  artery  breaks  up  at  once  into  a  number  of 
branches,  which  radiate  from  it,  at  different  angles,  to  the  several  parts 
of  the  lungs.  Consequently,  a  large  extent  of  surface  is  presented  to  the 
blood,  and  there  are  numerous  angular  projections  into  the  currents  ; 
both  which  conditions  are  calculated  to  induce  the  spontaneous  coagula- 
tion of  the  fibrin."  We  know  also  that  thrombosis  generally  occurs  in 
patients  of  feeble  constitution  often  debilitated  by  hemorrhage,  in  whom 
the  action  of  the  heart  is  much  weakened.  These  facts  of  themselves 
go  far  to  meet  the  objections  of  those  who  deny  the  possibility  of  spon- 
taneous coagulation  at  the  roots  of  the  pulmonary  arteries. 

Pesnlts  of  Post-mortem  Examinations. — The  records  of  post-mortem 
examinations  show  also  that  in  many  of  the  cases  the  right  side  of  the 
heart,  as  well  as  the  larger  branches  of  the  pulmonary  arteries,  contained 
firm,  leathery,  decolorized,  and  laminated  coagula,  which  could  not  have 
been  recently  formed.  The  advocates  of  the  purely  embolic  theory 
maintain  that  these  are  secondary  coagula  formed  round  an  embolus. 

^  See  especially  Bertin,  Des  Emholies,  p.  46  et  seq.  ^  Ibid.,  p.  149. 

^  Humphry,  On  the  Coagulation  of  the  Blood  in  the  Venous  Syste7n  during  Life. 


PUERPERAL   VENOUS  THROMBOSIS  AND  EMBOLISM.        625 

But  surely  the  mechanical  causes  which  are  sufficient  to  prevent  sponta- 
neous deposition  of  fibrin  would  also  suffice  to  prevent  its  gathering 
round  an  embolus — unless,  indeed,  the  obstruction  was  sufficient  to 
arrest  the  circulation  altogether,  when  death  would  occur  before  there 
was  any  time  for  a  secondary  dejDOsit.  Before  we  can  admit  the  possi- 
bility of  embolism  we  must  have  at  least  one  factor — that  is,  thrombosis 
in  a  peripheral  vessel — from  which  an  embolus  can  come.  In  many  of 
the  recorded  cases  nothing  of  the  kind  was  found,  and  although,  as  is 
argued,  this  may  have  been  overlooked,  yet  such  an  oversight  can  hardly 
always  have  been  made. 

Clinical  Facts  Supiwrt  this  View. — The  strongest  argument,  however, 
in  favor  of  the  spontaneous  origin  of  pulmonary  thrombosis  is  one  which 
I  originally  pointed  out  in  a  series  of  papers  "  On  Thrombosis  and  Em- 
bolism of  the  Pulmonary  Artery  as  a  Cause  of  Death  in  the  Puerperal 
State."  ^  I  there  showed,  from  a  careful  analysis  of  25  cases  of  sudden 
death  after  delivery  in  which  accurate  post-mortem  examinations  had 
been  made,  that  cases  of  spontaneous  thrombosis  and  embolism  may  be 
divided  from  each  other  by  a  clear  line  of  demarcation,  depending  on 
the  period  after  delivery  at  which  the  fatal  result  occurs.  In  7  out  of 
these  cases  there  was  distinct  evidence  of  embolism,  and  in  them  death 
occurred  at  a  remote  period  after  delivery ;  in  none  before  the  nineteenth 
day.  This  contrasts  remarkably  with  the  cases  in  which  the  post-mortem 
examination  affiDrdecl  no  evidence  of  embolism.  These  amounted  to  15 
out  of  the  25,  and  in  all  of  them,  with  one  exception,  death  occurred 
before  the  fourteenth  day,  often  on  the  second  or  third.  The  reason  of 
this  seems  to  be  that  in  the  former  time  is  required  to  admit  of  degener- 
ative changes  taking  place  in  the  deposited  fibrin  leading  to  separation 
of  an  embolus,  while  in  the  latter  the  thrombosis  corresponds  in  time, 
and  to  a  great  extent  no  doubt  also  in  cause,  to  the  original  peripheral 
thrombosis  from  which  in  the  former  the  embolus  was  derived.  Many 
cases  I  have  since  collected  illustrate  the  same  rule  in  a  very  curious  and 
instructive  way. 

Another  clinical  fact  I  have  observed  points  to  the  same  conclusion. 
In  one  or  two  cases  distinct  signs  of  pulmonary  obstruction  have- shown 
themselves  without  proving  immediately  fatal,  and  shortly  afterward 
peripheral  thrombosis,  as  evidenced  by  phlegmasia  dolens  of  one  extrem- 
ity, has  commenced.  Here  the  peripheral  thrombosis  obviously  followed 
the  central,  both  being  produced  by  identical  causes,  and  the  order  of 
events  necessary  to  uphold  the  purely  embolic  theory  was  reversed. 

I  hold,  then,  that  those  who  deny  the  possibility  of  spontaneous  coag- 
ulation in  the  heart  and  pulmonary  arteries  do  so  on  insufficient 
gnninds,  and  that  we  may  consider  it  to  be  an  occurrence,  rare  no 
doubt,  but  still  sufficiently  often  met  with,  and  certainly  of  sufficient 
importance,  to  merit  very  careful  study. 

History. — Dr.  Charles  D.  Meigs  of  Philadelphia  was  one  of  the  first 
to  direct  attention  to  spontaneous  coagulation  of  the  blood  in  the  right 
side  of  the  heart  and  pulmonary  arteries  as  a  cause  of  sudden  death  in 
the  puerperal  state.  The  occurrence  itself,  however,  has  been  carefully 
studied  by  Paget,  whose  paper  was  ]Mib]ished  in  1855,  four  years  before 

'  Lancet,  1867. 
40 


626  THE  PUERPERAL  STATE. 

Meigs  wrote  on  the  subject.^  It  is  true  that  none  of  Paget's  cases  hap- 
pened after  delivery,  but  he  none  the  less  clearly  apprehended  the  nature 
of  the  obstruction.  In  1855,  Hecker^  attributed  the  majority  of  these 
cases  to  embolism  proper ;  and  since  that  date  most  authors  have  taken 
the  same  view,  believing  that  spontaneous  coagulation  only  occurs  in 
excejjtional  cases,  such  as  those  in  which,  on  account  of  some  obstruc- 
tion in  the  lung  or  in  the  debility  of  the  last  few  hours  before  death, 
coagula  form  in  the  smaller  ramiiications  of  the  pulmonary  arteries  and 
gradually  creep  back^vard  toward  the  heart. 

Symjjtoras  of  Pulmonary  Obstruction. — The  symptoms  can  hardly  be 
mistaken,  and  there  seems  to  be  no  essential  difference  between  the 
symptomatology  of  spontaneous  and  embolic  obstructions,  so  that  the 
same  description  will  suffice  for  both.  In  a  larger  proportion  of  cases 
the  attack  comes  on  with  an  appalling  suddenness  which  forms  one  of  its 
most  striking  characteristics.  Nothing  in  the  condition  of  the  patient 
need  have  given  rise  to  the  least  suspicion  of  impending  mischief,  when 
all  at  once  an  intense  and  horrible  dyspnoea  comes  on ;  she  gasps  and 
struggles  for  breadth,  tears  off  the  coverings  from  her  chest  in  a  vain 
endeavor  to  get  more  air,  and  often  dies  in  a  few  minutes,  long  before 
medical  aid  can  be  had,  with  all  the  symptoms  of  asphyxia.  The  mus- 
cles of  the  face  and  thorax  are  violently  agitated  in  the  attempt  to  oxy- 
genate the  blood,  and  an  apjDcarance  closely  resembling  an  epilejDtic  con- 
vulsion may  be  presented.  The  face  may  be  either  pale  or  deeply 
cyanosed.  Thus  in  one  case  I  have  elsewhere  recorded,  which  was  an 
undoubted  example  of  true  embolism,  Mr.  Pedler,  the  resident  accou- 
cheur at  Xing's  College  Hosjaital,  m  ho  was  present  during  the  attack, 
writes  of  the  patient :  ^  "  She  was  suffering  from  extreme  dyspnoea,  the 
countenance  was  excessively  pale,  her  lips  white,  the  face  generally 
expressing  deep  anxiety."  In  another,  which  was  probably  an  example 
of  spontaneous  thrombosis^  occurring  on  the  tAvelfth  day  after  delivery, 
it  is  stated,  "  The  face  had  assumed  a  livid  purple  hue,  which  was  so 
remarkable  as  to  attract  the  attention  both  of  the  nurse  and  of  her 
mother,  who  was  with  her."  The  extreme  embarrassment  of  the  circu- 
lation is  shown  by  the  tumultuous  and  irregular  action  of  the  heart  in 
its  endeavor  to  send  the  venous  blood  through  the  obstructed  pulmonary 
arteries.  Soon  it  gets  exhausted,  as  shown  by  its  feeble  and  fluttering 
beat.  Tlie  pulse  is  thread-like  and  nearly  imperceptible,  the  respirations 
short  and  hurried,  but  air  may  be  heard  entering  the  lungs  freely.  The 
intelligence  during  the  struggle  is  unimpaired,  and  the  dreadful  con- 
sciousness of  impending  death  adds  not  a  little  to  the  patient's  sufferings 
and  to  the  terror  of  the  scene.  Such  is  an  imperfect  account  of  the 
symptoms  gathered  from  a  record  of  what  has  been  observed  in  fatal 
cases.  It  will  be  readily  understood  why,  in  the  presence  of  so  sudden 
and  awful  an  attack,  symptoms  have  not  been  recorded  with  the  accu- 
racy of  ordinary  clinical  observ^ation. 

Is  Recovery  Possible  f — A  question  of  great  practical  interest,  which 
has  been  entirely  overlooked  by  writers  on  the  subject,  is.  Have  we  any 

^  MedicorChir.  Trans.,  vol.  xxvii.  p.  162,  and  vol.  xxviii.  p.  352;  Philadelphia  Med- 
ical Examiner,  1849.  ^  Deutsche  klinicke,  1855.. 
3  Brit.  Med.  Journ.,  March  27,  1869.  ^  Obst.  Trans.,  vol.  xii.  p.  194. 


PUERPERAL   VENOUS  THROMBOSIS  AND  EMBOLISM.        627 

ground  for  supposing  that  there  is  a  possibility  of  recovery  after  symp- 
toms of  puhnonary  obstruction  have  developed  themselves  ?  That  such 
a  result  must  be  of  extreme  rarity  is  beyond  question^  but  I  have  little 
doubt  that  in  some  few  cases,  entirely  inexplicable  on  any  other  hypoth- 
esis, life  is  prolonged  until  the  coagulum  is  absorbed  and  the  pulmon- 
ary circulation  restored.  In  order  to  admit  of  this  it  is  of  course  essen- 
tial that  the  obstruction  be  not  sufficient  to  prevent  the  passage  of  a 
certain  quantity  of  blood  to  the  lungs  to  carry  on  the  vital  functions. 
The  history  of  many  cases  tends  to  show  that  the  obstructing  clot  was 
present  for  a  considerable  time  before  death,  and  that  it  was  only  when 
some  sudden  exertion  was  made,  such  as  rising  from  bed  or  the  like, 
calling  for  an  increased  supply  of  blood  which  could  not  pass  through 
the  occluded  arteries,  that  fatal  symptoms  manifested  themselves.  This 
was  long  ago  pointed  out  by  Paget,  ^  who  says  :  "  The  case  proves  that 
in  certain  circumstances  a  great  part  of  the  pulmonary  circulation  may 
be  arrested  in  the  course  of  a  week  (or  a  few  days  more  or  less)  without 
immediate  danger  to  life  or  any  indication  of  what  had  happened ; " 
and,  after  referring  to  some  illustrative  cases,  "  Yet  in  all  these  cases  the 
characters  of  the  clots  by  which  the  pulmonary  arteries  were  obstructed 
showed  plainly  that  they  had  been  a  week  or  more  in  the  pirocess  of  for- 
mation." If  we  admit  the  possibility  of  the  continuance  of  life  for  a 
certain  time,  we  must,  I  think,  also  admit  the  possibility,  in  a  few  rare 
cases,  of  eventual  complete  recovery.  What  is  required  is  time  for  the 
absorption  of  the  cloto  In  the  peripheral  venous  system  coagula  are 
constantly  removed  by  absorption.  So  strong,  indeed,  is  the  tendency 
to  this  that  Humphrey  observes  with  regard  to  it,  "  It  appears  that  the 
blood  is  almost  sure  to  revert  to  its  natural  channel  in  process  of  time."  ^ 
If,  then,  the  obstruction  be  only  partial,  if  sufficient  blood  pass  to  keep 
the  patient  alive,  and  a  sudden  supply  of  oxygenated  blood  is  not 
demanded  by  any  exertion  which  the  embarrassed  circulation  is  unable 
to  meet,  it  is  not  inconceivable  that  the  patient  may  live  until  the 
obstruction  is  removed. 

Illustrative  Cases. — Such  I  believe  to  be  the  only  explanation  of  cer- 
tain cases,  some  of  which  on  any  other  hypothesis  it  is  impossible  to 
understand.  The  symptoms  are  precisely  those  of  pulmonary  obstruc- 
tions, and  the  description  I  have  given  above  may  be  applied  to  them  in 
every  particular  ;  and,  after  repeated  paroxysms,  each  of  which  seems  to 
threaten  immediate  dissolution,  an  eventual  recovery  takes  place. 
What,  then,  I  am  entitled  to  ask,  can  the  condition  be  if  not  tliat  which 
I  suggest?  As  the  question  I  am  considering  has  never,  so  far  as  I  am 
aware,  l)ecn  treated  of  by  any  other  writer,  I  may  be  permitted  to 
state,  very  briefly,  the  facts  of  one  or  two  of  the  cases  on  which  I 
found  my  argument,  some  of  which  I  have  already  published  in  detail 
elsewhere : 

K.  II.,  flclinato  yoiini;  liidy.  Labor  oasy.  First  child.  Profuso  post-partum 
homorrPiatfO.  Did  wtdl  until  tho  wiivftnth  <lay,  duriiiff  tin;  whole  of  which  ,slio  folt 
woak.  Same  day  an  alarinini^  attack  of  dysntifioa  caiiio  on.  For  .sovcn-al  days  she 
remainod  in  a  very  critical  condition,  the  .sliiflitcHt  extortion  brin^in^  on  the  attacks. 
A  slight  blowing  murmur  heard  for  a  few  days  at  the  base  of  the  heart,  and  then 

'  Op.  cil.,  p.  358.  ^  Med.-Chir.  Tram.,  vol.  xxvii.  p.  14. 


628  THE  PUERPERAL  STATE. 

disappeared.  For  two  months  patient  remained  in  the  same  state.  As  long  as  she 
was  in  the  recumbent  position  she  felt  pretty  comfortable,  but  any  attempt  at  sit- 
ting up  in  bed  or  any  unusual  exertion  immediately  brought  on  the  embarrassed 
respiration.  During  all  this  time  it  was  found  necessary  to  administer  stimulants 
profusely  to  ward  otf  the  attacks.     Eventually  the  patient  recovered  completely. 

Q.  F.,  a3t.  44.  Mother  of  twelve  children.  Confined  on  July  6.  On  the  eleventh 
day  she  went  to  bed  feeling  well.  There  was  no  swelling  or  discomfort  of  any  kind 
about  the  lower  extremities  at  this  time.  Aljout  half-past  3  a.  m.  she  was  sitting 
up  in  bed,  when  she  was  suddenly  attacked  with  an  indescribable  sense  of  oppres- 
sion in  the  chest,  and  fell  back  in  a  semi-unconscious  state,  gasping  for  breath. 
She  remained  in  a  very  critical  condition,  with  the  same  symptoms  of  embarrassed 
respiration,  for  three  days,  when  they  gradually  passed  away.  Two  days  after  the 
attack  phlegmasia  dolens  came  on,  the  leg  swelled,  and  remained  so  for  several 
months. 

This  case  is  an  example  of  the  fact  I  have  already  referred  to,  of 
phlegmasia  dolens  coming  on  afier  the  symptoms  of  pulmonary  obstruc- 
tion had  manifested  themselves ;  the  inference  being  that  both  depended 
on  similar  causes  operating  on  two  distinct  parts  of  the  circulatory 
system. 

C.  H.,  set.  24.  Confined  of  her  first  child  on  August  20,  1867.  Thirty  ho^rs 
after  delivery  she  complained  of  great  weakness  and  dyspnoea.  This  was  alleviated 
by  the  treatment  employed,  but  on  the  ninth  day,  after  making  a  sudden  exertion, 
the  dyspnoea  returned  with  increased  violence,  and  continued  unabated  until  I  saw 
the  patient  on  September  4,  fourteen  days  after  her  confinement.  The  folloAving 
are  the  notes  of  her  condition,  made  at  the  time  of  the  visit:  "  I  found  her  sitting 
on  the  sofa  propped  up  with  pillows,  as  she  said  she  could  not  breathe  in  the 
recumbent  position.  The  least  excitement  or  talking  brought  on  the  most  aggra- 
vated dyspnoea,  which  was  so  bad  as  to  threaten  almost  instant  death.  Her  suffer- 
ings during  these  paroxysms  were  terrible  to  witness.  She  panted  and  struggled 
for  breath,  and  her  chest  heaved  with  short,  gasping  respirations.  She  could  not 
even  bear  any  one  to  stand  in  front  of  her,  waving  them  away  with  her  hand  and 
calling  for  more  air.  These  attacks  were  very  frequent,  and  were  brought  on  liy 
the  most  trivial  causes.  She  talked  in  a  low,  suppressed  voice,  as  if  she  could  not 
spare  breath  for  articulation.  On  auscultation  air  was  found  to  enter  the  lungs 
freely  in  every  direction,  both  in  front  and  behind.  Immediately  over  the  site  of 
the  pulmonary  arteries  there  was  a  distinct  harsh,  rasping  murmur,  confined  to  a 
very  limited  space  and  not  propagated  either  upward  or  downward.  The  heart- 
sounds  Avere  feeble  and  tumultuous."  These  symptoms  led  me  to  diagnose  pul- 
monary oljstruction,  and  I  of  course  gave  a  most  unfavorable  prognosis,  but  to  my 
great  surprise  the  patient  sloAvly  recovered.  I  saw  her  again  six  weeks  later,  when 
her  heart-sounds  were  regular  and  distinct  and  the  murmur  had  completely  disap- 
peared. 

E.  E.,  a3t.  42,  was  confined  for  the  first  time  on  November  5,  1873,  in  the  sixth 
month  of  utero-gestation.  She  had  severe  post-partum  hemorrhage,  depending  on 
partially-adherent  placenta,  which  was  removed  artificially.  She  did  perfectly  well 
until  the  fourteenth  day  after  delivery,  when  she  Avas  suddenly  attacked  Avith 
intense  dyspnoea,  aggravated  in  paroxysms.  Pulse  pretty  full,  130,  but  distinctly 
intermittent.  Air  entered  lungs  freely.  The  heart's  action  was  fluttering  and 
irregular,  and  at  the  juncture  of  the  fourth  and  fifth  ribs  Avith  the  sternum  there 
was  a  loud  bloAving,  systolic  murmur.  This  Avas  certainly  non-existent  before,  as 
the  heart  had  been  carefully  auscultated  before  administering  chloroform  during 
labor.  P'or  tAvo  days  the  patient  remained  in  the  same  state,  her  death  being 
almost  momentarily  expected.  On  the  21st — that  is,  tAvo  days  after  the  appearance 
of  the  chest  symptoms — phlegmasia  dolens  of  a  severe  kind  developed  itself  in  the 
right  thigh  and  leg.  She  continued  in  the  same  state  for  many  days,  lying  more 
or  less  tranquilly,  but  haA'ing  paroxysms  of  the  most  intense  apnoea,  varying  from 
tAvo  to  six  or  eight  in  the  twenty-four  hours.  No  one  Avho  saw  her  in  one  of  these 
could  have  expected  her  to  live  through  it.  Shortly  after  the  first  appearance  of 
the  paroxysms  it  Avas  observed  that  the  cellular  tissue  of  the  neck  and  part  of  the 


PUERPERAL   VENOUS  THROMBOSIS  AND  EMBOLISM.        629 

face  became  swollen  and  cedematous,  giving  an  appearance  not  unlike  that  of 
phlegmasia  dolens.  The  attacks  were  ahvays  relieved  by  stimulants.  These  she 
incessantly  called  for,  declaring  that  she  felt  they  kept  her  alive.  During  all  this 
time  the  mind  was  clear  and  collected.  The  pulse  varied  from  110  to  130 ;  respira- 
tions about  60 ;  temperature  101°  to  102.5°.  By  slow  degrees  the  patient  seemed 
to  be  rallying.  The  paroxysms  diminished  in  number,  and  after  December  1st  she 
never  had  another,  and  the  breathing  became  free  and  easy.  The  pulse  fell  to  80 
and  the  cardiac  murmur  entirely  disappeared.  The  patient  remained,  however, 
very  weak  and  feeble,  and  the  debility  seemed  to  increase.  Toward  the  second 
week  in  December  she  became  delirious,  and  died,  apparently  exhausted,  without 
any  fresh  chest  symptoms,  on  the  19th  of  that  month.  No  post-mortem  examina- 
tion was  allowed. 

I  have  narrated  this  case,  although  it  terminated  fatally,  because  I 
hold  it  to  be  one  of  the  class  I  am  considering.  The  death  was  certainly 
not  due  to  the  obstruction,  all  symptoms  of  which  had  disappeared,  but 
apparently  to  exhaustion  from  the  severity  of  the  former  illness.  It 
illustrates,  too,  the  simultaneous  appearance  of  symptoms  of  pulmonary 
obstruction  and  peripheral  thrombosis.  The  swelling  of  the  neck  was 
a  curious  symptom  which  has  not  been  recorded  in  any  other  cases,  and 
may  possibly  be  a  further  proof  of  the  analogy  between  this  condition 
and  phlegmasia  dolens. 

Such  Cases  can  only  Depend  on  Pulmonary  Obstruction. — Now,  it 
may,  of  course,  be  argued  that  these  cases  do  not  prove  my  thesis,  inas- 
much as  I  only  assume  the  presence  of  a  coagulum.  But  I  may  fairly 
ask  in  return,  AVhat  other  condition  could  possibly  explain  the  symp- 
toms ?  They  are  precisely  those  which  are  noticed  in  death  from  un- 
doubted pulmonary  obstruction.  No  one  seeing  one  of  them,  or  even 
reading  an  account  of  the  symptoms,  while  ignorant  of  the  result,  could 
hesitate  a  single  instant  in  the  diagnosis.  Surely,  then,  the  inference  is 
fair  that  they  depended  on  the  same  cause.  In  the  very  nature  of  things 
my  hypothesis  cannot  be  verified  by  post-mortem  examination,  but  there 
is  at  least  one  case  on  record  in  which,  after  similar  symptoms,  a  clot 
was  actually  found.  The  case  is  related  by  Dr.  Richardson.^  It  was 
that  of  a  man  who  for  weeks  had  symptoms  precisely  similar  to  those 
observed  in  the  cases  I  have  narrated.  In  one  of  his  ao;onizinp;  strup;o^les 
for  breath  he  died,  and  after  death  it  was  found  "  that  a  fibrinous  baud, 
having  its  hold  in  the  ventricle,  extended  into  the  pulmonary  artery." 
This  observation  proves  to  a  certainty  that  life  may  continue  for  weeks 
after  deposition  of  a  coagulum  ;  and,  moreover,  this  condition  was  pre- 
cisely what  we  should  anticipate,  since,  of  course,  the  obstructing  coagu- 
lum must  necessarily  be  small,  otherwise  the  vital  functions  would  be 
inuned lately  arrested. 

Cardiac  Murimirs  in  Pulmonary  Obstruction. — Tliere  is  a  symptom 
noted  in  two  of  the  above  cases,  and  to  a  less  extent  in  a  third,  which 
has  not  been  mentioned  in  any  account  of  fatal  cases  occurring  after 
delivery — viz.  a  murmur  over  the  site  of  the  pulmonary  arteries.  It  is 
a  sign  we  should  naturally  expect,  and  very  possibly  it  would  bo  met 
W'ith  in  fatal  cases  if  attention  were  particularly  directed  to  the  point. 
In  b(jth  these  instances  it  was  exceedingly  well  marked,  and  in  both  it 
entirely  disappeared  when  the  symptoms  abated.     The  j)robability  of 

*  Clinical  EnmyH,  p.  224  el  seq. 


630  THE  PUERPERAL  STATE. 

such  a  murmur  being  audible  in  cases  of  thrombosis  of  the  pulmonary- 
artery  has  been  recognized  by  one  of  our  highest  authorities  in  cardiac 
disease,  who  actually  observed  it  in  a  non-puerperal  case.  In  the  last 
edition  of  his  work  on  diseases  of  the  heart  Dr.  Walshe^  says:  "The 
only  physical  condition  connected  Avith  the  vessel  itself  would  jJi'obably 
be  systolic  basic  murmur  following  the  course  of  the  pulmonary  main 
trunk  and  of  its  immediate  divisions  to  the  left  and  right  of  the  ster- 
num. This  sign  I  most  certainly  heard  in  an  old  gentleman  whose  life 
was  brought  to  a  sudden  close,  in  the  course  of  an  acute  affection,  by 
coagulation  in  the  pulmonary  artery,  and  to  a  moderate  extent  in  the 
right  ventricle," 

Similar  cases  have  probably  been  overlooked  or  misinterpreted.  Many 
seem  to  have  been  attributed  to  shock,  in  the  absence  of  a  better  explana- 
tion— a  condition  to  which  they  bear  no  kind  of  resemblance. 

Causes  of  Death. — The  precise  mode  of  death  in  pulmonary  obstruc- 
tion, whether  dependent  on  thrombosis  or  embolism,  has  given  rise  to 
considerable  diiference  of  opinion.  Virchow  attributes  it  to  syncope  ^ 
depending  on  stoppage  of  the  cardiac  contraction.  Panum,^  on  the  other 
hand,  contests  this  view,  maintaining  that  the  heart  continues  to  beat 
even  after  all  signs  of  life  have  ceased.  Certainly,  tumultuous  and 
irregular  pulsations  of  the  heart  are  prominent  symptoms  in  most  of 
the  recorded  cases,  and  are  not  reconcilable  with  the  idea  of  syncope. 
Panum's  own  theory  is  that  death  is  the  result  of  cerebral  anaemia. 
Paget  seems  to  think  that  the  mode  of  death  is  altogether  peculiar,  in 
some  respects  resembling  syncope,  in  others  anaemia.  Bertin,  who  has 
discussed  the  subject  at  great  length,  attributes  the  fatal  result  purely  to 
asphyxia.  The  condition,  indeed,  is  in  all  respects  similar  to  that  state, 
the  oxygenation  of  the  blood  being  prevented,  not  because  air  cannot  get 
to  the  blood,  but  because  blood  cannot  get  to  the  air.  The  symptoms 
also  seem  best  explained  by  this  theory :  the  intense  dyspncea,  the  terri- 
ble struggle  for  air,  the  preservation  of  intelligence,  the  tumultuous 
action  of  the  heart,  are  certainly  not  characteristic  either  of  syncope  or 
anaemia. 

Post-mortem  Appearanees  of  Clots. — The  anatomical  character  of  the 
clots  seems  to  vary  considerably.  Ball,  by  Avhom  they  have  been  most 
carefully  described,  believes  that  they  generally  commence  in  the  smaller 
ramifications  of  the  arteries,  extending  backward  toward  the  heart  and 
filling  the  vessels  more  or  less  completely.  Toward  its  cardiac  extremity 
the  coagulum  terminates  in  a  rounded  head,  in  which  respect  it  resembles 
those  spontaneously  formed  in  the  peripheral  veins.  It  is  non-adherent 
to  the  coats  of  the  vessels,  and  the  blood  circulates,  when  it  can  do  so 
at  all,  between  it  and  the  vascular  walls.  Such  clots  are  white,  dense, 
and  of  a  homogeneous  structure,  consisting  of  layers  of  decolorized 
fibrin,  firm  at  the  periphery,  where  the  fibrin  has  been  most  recently 
deposited,  and  softened  in  the  centre,  where  am^daceous  or  fatty  degen- 
eration has  commenced.  Ball  maintains  that  if  the  coagulum  have  com- 
menced in  the  larger  branches  of  the  arteries,  it  must  have  first  begun 
in  the  ventricle  and  extended  into  them.     According  to  Humphrey,  the 

^  Walshe,  On  Diseases  of  the  Heart,  4th  ed.,  1873. 

^  Gesamm.  AbhandL,  1862,  p.  316.  ^  Virchow' s  Archiv,  1863. 


PUERPERAL    VENOUS  THROMBOSIS  AND  EMBOLISM.        631 

same  changes  take  place  in  pulmonary  as  in  peripheral  thrombi,  and  they 
may  become  adherent  to  the  walls  of  the  vessels  or  converted  into  threads 
or  bands.  When  the  obstruction  is  due  to  embolism,  provided  the  case 
is  a  well-marked  one  and  the  embolus  of  some  size,  the  appearances  pre- 
sented are  different.  We  have  no  longer  a  laminated  and  decolorized 
coagulum  with  a  rounded  head,  similar  to  a  peripheral  thrombus.  The 
obstruction  in  this  case  generally  takes  place  at  the  point  of  bifurcation 
of  the  artery,  and  we  there  meet  with  a  grayish-white  mass,  contrasting 
remarkably  with  the  more  recently-deposited  fibrin  before  and  behind  it. 
It  may  be  that  the  form  of  the  embolus  shows  that  it  has  recently  been 
separated  from  a  clot  elsewhere ;  and  in  many  cases  it  has  been  possible 
to  fit  the  travelled  portion  to  the  extremity  of  the  clot  from  which  it 
has  been  broken.  We  may  also,  perhaps,  find  that  the  embolus  has 
undergone  an  amount  of  retrograde  metamorphosis  corresponding  with 
that  of  the  peripheral  thrombus  from  which  we  suppose  it  to  have  come, 
but  differing  from  that  of  the  more  recently-deposited  fibrin  around  it.  It 
must  be  admitted,  however,  that  the  anatomical  peculiarities  of  the  co- 
agula  will  by  no  means  always  enable  us  to  trace  them  to  their  true 
origin.  In  many  cases  emboli  may  escape  detection  from  their  smallness 
or  from  the  quantity  of  fibrin  surrounding  them. 

Treatment. — But  few  words  need  be  said  as  to  the  treatment  of  pul- 
monary obstruction.  In  a  large  majority  of  cases  the  fatal  result  so 
rapidly  follows  the  appearance  of  the  symptoms  that  no  time  is  given  us 
even  to  make  an  attempt  to  alleviate  the  patient's  sufferings.  Should 
we  meet  with  a  case  not  immediately  fatal,  it  seems  that  there  are  but 
two  indications  of  treatment  affording  the  slightest  rational  ground  of 
hope  :  '  " 

1.  To  keep  the  patient  alive  by  the  administration  of  stimulants —   'Ji;;^mamU4 

brandy,  ether,  ammonia,  and  the  like — to  be  repeated  at  intervals  corre-   

sponding  to  the  intensity  of  the  paroxysms  and  the  results  produced. 

In  the  cases  I  have  above  narrated  in  which  recovery  ensued  this  took 
the  place  of  all  other  medication.  Possibly  leeches  or  dry  cupping  to 
the  chest  might  prove  of  some  service  in  relieving  the  circulation.         "'■   ' 

2.  To  enjoin  the  most  absolute  and  complete  repose.     The  object  of    aX^a/UJs 
this  is  evident.     Tlie  only  chance  for  the  patient  seems  to  be  that  the    •  - 
vital  functions  should  be  carried  on  until  the  coagulum  has  been  ab- 
sorbed, or  at  least  until  it  has  been  so  much  lessened  in  size  as  to  admit 

of  blood  passing  it  to  the  lungs.  The  slightest  movements  may  give 
rise  to  a  fatal  paroxysm  of  dyspncea  from  the  increased  supply  of  oxy- 
genated blood  required.  It  must  not  be  forgotten  that  in  a  large  pro- 
portion of  cases  death  immediately  followed  some  exertion  in  itself  triv- 
ial, such  as  rising  out  of  bod.  Too  mucli  attention,  then,  cannot  be  given 
to  this  point.  The  patient  should  bo  absolutely  still ;  she  should  be  fed 
with  abundance  of  fluid  food,  such  as  milk,  strong  soiq)s,  and  the  like, 
and  shtjuld  on  no  account  be  permitted  to  raise  herself  in  bed  orattem])t 
the  sliglitest  muscular  exertion.  If  we  are  fortunate  enough  to  meet 
with  a  case  a])par('ntly  tending  to  recovery,  these  ])rccauti()ns  nuist  be 
carried, on  long  after  tlic  severity  of  the  symptoms  has  lessened,  for  a 
moment's  imprudence  may  suffice  to  bring  them  back  in  all  their  orig- 
inal intensity. 


632  THE  PUERPERAL  STATE. 

Bertin/  indeed,  recommends  a  system  of  treatment  very  different  from 
this.  In  the  vain  hope  that  the  violent  effort  induced  may  cause  the  dis- 
placement of  the  impacted  embolus  (to  which  alone  he  attributes  pul- 
monary obstruction)  he  recommends  the  administration  of  emetics. 
Few,  I  fancy,  will  be  found  bold  enough  to  attempt  so  hazardous  a  plan 
of  treatment. 

Various  drugs  have  been  suggested  in  these  cases.  Richardson  ^ 
recommended  ammonia,  a  deficiency  of  which  he  at  that  time  believed 
to  be  the  chief  cause  of  coagulation.  He  has  since  advised  that  liquor 
ammoniee  should  be  given  in  large  doses,  20  minims  every  hour,  in  the 
hope  of  causing  solution  of  the  deposited  fibrin ;  and  he  has  stated  that 
he  has  seen  good  results  from  the  practice.  Others  advise  the  admin- 
istration of  alkalies,  in  the  hope  that  they  may  favor  absorption.  The 
best  that  can  be  said  for  them  is  that  they  are  not  likely  to  do  much 
harm. 

Puerperal  Pleuro-pneumonia. — This  is  perhaps  the  best  place  to  men- 
tion an  important  but  little- understood  class  of  cases  which  I  believe  to 
be  less  uncommon  than  is  generally  supposed.  I  refer  to  severe  pleuro- 
pneumonia occurring  in  connection  with  the  puerperal  state,  but  not  dis- 
tinctly associated  with  septicsemia.  Two  carefully-observed  cases  of  this 
kind  are  recorded  by  MacDonald,  occurring  in  his  practice ;  I  myself 
have  met  Math  three  very  marked  examples  within  the  past  three  years, 
one  of  which  proved  fatal,  the  other  two  giving  rise  to  most  serious 
illness,  from  which  the  patient  recovered  with  difficulty. 

Peculiarities  of  these  Cases. — So  far  as  my  own  observation  goes,  there 
are  marked  peculiarities  in  such  cases  which  clearly  differentiate  them  from 
the  ordinary  course  of  pneumonia.  The  onset  is  sudden  and  unconnected 
with  exposure  to  cold  or  other  cause  of  lung  disease ;  there  is  no  definite 
crisis,  but  a  continuous  pyrexia,  of  moderate  intensity,  lasting  a  variable 
time ;  and  the  physical  signs  differ  from  those  of  ordinary  pnemnonia. 

Physical  Signs. — In  MacDonald's  case,  as  well  as  in  my  own,  they 
were  peculiar  in  this  respect,  that  there  was  very  slight  crepitation, 
marked  rusty  sputum,  and  a  wooden  dulness,  much  more  intense  than 
in  ordinary  pneumonia,  extending  over  a  large  lung-space,  with  a  very 
slio;ht  entrance  of  air  into  the  lung-tissue.  It  is  also  remarkable  that  a 
very  large  proportion  of  the  cases  was  associated  with  phlegmasia  dolens. 
Thus,  it  existed  in  one  of  MacDonald's  two  cases,  and  in  two  out  of  my 
own  three.  Like  phlegmasia  dolens,  moreover,  the  disease  generally 
commenced  some  weeks  after  delivery ;  my  own  cases,  for  example, 
occurred  respectively  fifteen,  tM'enty-eight,  and  thirty-five  days  after 
labor.  It  is  difficult  to  believe  that  there  is  not  some  connection  between 
these  two  conditions,  and  there  is  much  in  their  peculiar  history  to  lead 
to  the  belief  that  such  forms  of  lung  disease  depend,  in  fact,  on  throm- 
botic or  embolic  obstruction  of  the  minute  bi^anches  of  the  pulmonary 
arteries,  caused  by  conditions  similar  to  those  which  have  produced  the 
phlebitic  obstructions  in  the  lower  extremities.  In  the  absence  of  careful 
post-mortem  examination  this  hypothesis  is  clearly  not  susceptible  of 
proof.  MacDonald,  while  admitting  that  "a  limited  thrombosis  of 
the  pulmonary  arteries  would  no  doubt  explain  the  facts  of  the  cases," 

^  Op.  ciL,  p.  393.  '  Heart  Disease  during  Pregnancy,  p.  209. 


PVEBPEBAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM.     633 

is  rather  inclined  to  "  seek  the  chief  explanation  of  their  occurrence  in 
the  alterations  which  the  pregnant  and  puerperal  conditions  impress 
upon  the  blood  and  the  blood-vascular  system." 

I  confess  that,  to  my  mind,  the  former  hypothesis  is  not  only  the  most 
definite,  but  the  one  which  most  readily  explains  all  the  peculiarities  of 
these  cases.  I  cannot,  however,  do  more  than  suggest  it,  in  the  hope 
that  further  observations,  and  especially  carefully-conducted  autopsies, 
may  throw  some  light  on  this  obscure  and  little-studied  subject. 

Treatment. — As  regards  treatment,  it  is  obvious  that  it  must  be  con- 
ducted on  general  principles,  carefully  avoiding  over-severe  measures, 
and  supporting  the  patient  through  a  trial  to  the  system  that  must  ne- 
cessarily be  severe. 


CHAPTER  yil. 

PUERPERAL  ARTERIAL  THROMBOSIS  AND  EMBOLISM. 

The  same  condition  of  the  blood  which  so  strongly  predisposes  to 
coagulation  in  the  vessels  through  which  venous  blood  circulates  tends 
to  similar  results  in  the  arterial  system.  These,  however,  are  by  no 
means  so  common,  and  do  not,  as  a  rule,  lead  to  such  important  conse- 
quences. The  subject  has  been  but  little  studied,  and  almost  all  our 
knowledge  of  it  is  derived  from  a  very  interesting  essay  by  Sir  James 
Simpson.^  As  I  have  devoted  so  much  space  to  the  consideration  of 
venous  thrombosis  and  embolism,  I  shall  but  briefly  consider  the  effects 
of  arterial  obstruction. 

Causes. — In  a  considerable  number  of  recorded  cases  the  obstruction 
has  resulted  from  the  detachment  of  vegetations  deposited  on  the  cardiac 
valves,  the  result  of  endocarditis,  either  produced  by  antecedent  rheuma- 
tism or  as  a  complication  of  the  puerperal  state.  Sometimes  the  obstruc- 
tion seems  to  depend  on  some  general  bloocl-dyscrasia,  similar  to  that  pro- 
ducing venous  thrombosis,  or  on  some  local  change  in  the  artery  itself. 
Thus,  Simpson  records  a  case  apparently  produced  by  local  arteritis, 
which  caused  acute  gangrene  of  bc^th  local  extremities,  ending  fatally  in 
the  third  week  after  delivery.  ♦  In  other  cases  it  has  been  attributed  to 
coagulation  fijllowing  sj^ontaneous  laceration  and  corrugation  of  the 
internal  coat  of  the  artery. 

Symptoms. — The  symptoms  of  puerperal  arterial  obstruction  must  of 
course  vary  with  the  particular  arteries  affected.  Those  with  the  ob- 
stru(!tion  of  which  we  are  most  familiar  are  the  cerebral,  the  brachial, 
and  the  femoral.  The  eff('cts  ])ro(luce(l  nuist  also  be  niodificd  by  the 
size  of  the  embolus  and  tlie  more  or  l(!s.s  complete  obstruction  it  pro- 
duces. Thus,  for  examj)l(',  if  th(!  middle  c('r(tl)ra]  ariciy  be  blocked  up 
entirely,  the  functions  of  those  portions  of  the  brain  supplied  by  it  will 
be  more  or  less  completely  arrested,  and  hemiplegia  of  the  opposite  side 

^Selected  Obnt.  Worlca,  vol.  i.  p.  523. 


634  THE  PUERPERAL  STATE. 

of  the  body,  followed  by  softening  of  the  brain-texture,  will  probably 
result.  If  the  nervous  symptoms  be  developed  gradually  or  inerease  in 
intensity  after  their  first  appearance,  it  may  be  that  an  obstruction,  at 
first  incomplete,  has  increased  by  the  deposition  of  fibrin  around  it.  So 
the  occasional  sudden  supervention  of  blindness,  with  destruction  of  the 
eyeball — cases  of  which  are  recorded  by  Simpson — not  improbably  de- 
pends on  the  occlusion  of  the  ophthalmic  artery,  the  function  of  the  organ 
depending  on  its  supply  through  the  single  artery.  The  effects  of  obstruc- 
tion of  the  visceral  arteries  in  the  puerperal  state  are  entirely  unknown, 
but  it  is  far  from  unlikely  that  further  investigation  may  prove  them  to 
be  of  great  importance.  In  the  extremities  arterial  obstruction  produces 
effects  which  are  well  rnarked.  They  are  classified  by  Simpson  under 
the  following  heads  :  1.  Arrest  of  pulse  beloiv  the  site  of  obstruction. — 
This  has  been  observed  to  come  on  either  suddenly  or  gradually,  and  if 
the  occlusion  be  in  one  of  the  large  arterial  trunks,  it  is  a  symptom  which 
a  careful  examination  will  readily  enable  us  to  detect.  2.  Increased  force 
of  pulsation  in  the  artei-ies  above  the  seat  of  obstruction.  3.  Fall  in  the 
temperature  of  the  limb. — This  is  a  symptom  which  is  easily  appreciable 
by  the  thermometer,  and  when  the  main  artery  of  the  limb  is  occluded 
the  coldness  of  the  extremity  is  well  marked.  4.  Lesions  of  motor  and 
sensory  functions,  parcdysis,  neuralgia,  etc.  etc. — Loss  of  power  in  the 
affected  limb  is  often  a  prominent  symptom,  and  when  it  comes  on  sud- 
denly, and  is  complete,  the  main  artery  ^vill  probably  be  occluded.  It 
may  be  diagnosed  from  paralysis  depending  on  cerebral  or  spinal  causes 
by  the  absence  of  head-symptoms,  by  the  history  of  the  attack,  and  by 
the  presence  of  other  indications  of  arterial  obstruction,  such  as  loss  of 
pulsation  in  the  artery,  fall  of  temperature,  etc.  The  sensory  functions 
in  these  cases  are  generally  also  seriously  disturbed — not  so  much  by  loss 
of  sensation  as  by  severe  pain  and  neuralgia.  Sometimes  the  pain  has 
been  excessive,  and  occasionally  it  has  been  the  first  symptom  ^^•hich 
directed  attention  to  the  state  of  the  limb.  5.  Gangrene  beloiv  or  beyond 
the  seat  of  artericd  obstruction. — Several  interesting  cases  are  recorded  in 
which  gangrene  has  followed  arterial  obstruction.  Generally  speaking, 
gangrene  will  not  follow  occlusion  of  the  main  arterial  trunk  of  an 
extremity,  as  the  collateral  circulation  becomes  soon  sufficiently  devel- 
oped to  maintain  its  vitality.  In  many  of  the  cases  either  thrombi  have 
obstructed  the  channels  of  collateral  circulation  as  well,  or  the  veins  of 
the  limb  have  also  been  blocked  up.  When  such  extensive  obstructions 
occur,  they  obviously  cannot  be  embolic^  but  must  depend  on  a  local 
thrombosis  traceable  to  some  general  blood-dyscrasia  depending  on  the 
puerperal  state. 

Treatment. — Little  can  be  said  of  such  cases  as  to  the  treatment,  which 
must  vary  with  the  gravity  and  nature  of  the  symptoms  in  each.  Beyond 
absolute  rest  (in  the  hope  of  eventual  absorption  of  the  thrombus  or  em- 
bolus), generous  diet,  attention  to  the  general  health  of  the  patient,  and 
sedative  applications  to  relieve  the  local  pain,  there  is  little  in  our  power. 
Should  gangrene  of  an  extremity  supervene  in  a  puerperal  patient,  the 
case  must  necessarily  be  wellnigh  hopeless.  Simpson,  however,  records 
one  instance  in  Mdiich  amputation  was  performed  above  the  line  of 
demarcation,  the  patient  eventually  recovering. 


CAUSES  OF  SUDDEN  DEATH  DURING  LABOR.  635 


CHAPTER   VTTI. 

OTHER  CAUSES  OF  SUDDEN  DEATH  DURING  LABOR  AND  THE 
PUERPERAL  STATE. 

Various  Causes  of  Sudden  Death. — A  large  number  of  the  cases  in 
which  sudden  death  occurs  during  or  after  delivery  find  their  explana- 
tion, as  I  have  already  pointed  out,  in  thrombosis  or  embolism  of  the 
heart  and  pulmonary  arteries.  Probably  many  cases  of  the  so-called 
idiopathic  asphyxia  were,  in  fact,  examples  of  this  accident,  the  true 
nature  of  which  had  been  misunderstood.  Besides  these,  there  are  no 
doubt  many  other  conditions  which  may  lead  to  a  suddenly  fatal  result 
in  connection  with  parturition. 

Some  of  these  are  of  an  organic,  others  of  a  functional,  nature. 

Organic  Causes. — Among  the  former  may  be  mentioned  cases  in  which 
the  straining  efforts  of  the  second  stage  of  labor  have  produced  death  in 
patients  suffering  from  some  pre-existent  disease  of  the  heart.     Rupture    . 
of  that  organ  has  probably  occurred  from  fatty  degeneration  of  its  walls,    i ,  \, 
Dehous^  narrates  an  instance  in  which  the  efforts  of  labor  caused  the      '' 
rupture  of  an  aneurism.    Another  case,  from  interference  with  the  action    i\^^ 
of  the  heart  in  a  patient  who  had  pericardial  effusion,  is  narrated  by     ' 
Ranisbotham.     Dr.  Devilliers  relates  an  instance  occurring  in  a  young 
woman  during  the  second  stage  of  labor.     The  heart  was  found  to  be 
healthy,  but  the  lungs  were  intensely  congested  and  blood  was  exten- 
sively extravasated  all  through  their  texture.    This  was  probably  caused 
by  pulmonary  congestion  and  apoplexy,  produced  by  the  severe  strain- 
ing efforts.     Many  cases  from  effusion  of  blood  into  the  brain-substance 
or  on  its  surface  are  on  record,  no  doubt  in  patients  who,  from  arterial 
degeneration  or  other  causes,  were  predisposed  to  apoplectic  effusions. 
The  so-called  apoplectic  convulsions,  formerly  described  in  most  works 
on  obstetrics  as  a  variety  of  puerperal  convulsions,  are  evidently  nothing 
more  than  apoplexy  coming  on  during  or  after  labor.     As  regards  their 
pathology,  they  do  not  seem  to  differ  from  ordinary  cases  of  apoplexy  in 
the  non-pregnant  condition.     One  example  is  recorded  of  death  which 
was  attributed  to  rupture  of  the  diaphragm  from  excessive  action  in  the 
second  stage. 

Functional  Causes. — Among  the  causes  of  death  which  cannot  be 
traced  to  some  distin(it  organic  lesion  may  be  classed  cases  of  syncope, 
shock,  and  exhaustion.  Many  instances  of  this  kind  are  recorded.  Thus, 
in  some  women  of  susceptible  nervous  organization  the  severity  of  tlie 
suffering  appears  to  bring  on  a  condition  similar  to  that  produced  by 
excessive  shock  or  exhaustion,  which  has  not  unfrequently  ])roved  fatal. 
Several  examples  of  this  kind  liave  been  cited  by  McClintock.^  It  is 
also  not  unlikely  that  sudden  syncope  sometimes  produces  a  fatal  result 
during  or  after  labor.     Most  ciises  of  death  otiierwise  inexplicabh;  used 

'  Dehous,  Sur  leu  Moris  subiles.  ^  Union  medic,  1853. 


636  THE  PUERPERAL  STATE. 

to  be  referred  to  this  cause ;  but  accurate  autopsies  were  seldom  made, 
and  even  when  they  were — the  important  effects  of  pulmonary  coagula 
being  unknown — it  is  more  than  probable  that  the  true  cause  of  death 
was  overlooked.  It  has  been  supposed  that  the  sudden  removal  of 
pressure  from  the  veins  of  the  abdomen  by  the  emptying  of  the  gravid 
uterus  after  delivery  may  favor  an  increased  afflux  of  blood  into  the 
lower  parts  of  the  body,  and  thus  tend  to  an  anaemic  condition  of  the 
brain  and  the  production  of  syncope.  However  this  may  be,  the  possi- 
bility of  its  occurrence,  and  its  manifest  danger  in  a  recently-delivered 
woman,  are  sufficient  reasons  for  enforcing  the  recumbent  position  after 
labor  is  over.  In  some  of  the  cases  the  syncope  was  evidently  produced 
by  the  patient's  suddenly  sitting  upright. 

Death  from  Air  in  the  Veins. — Some  cases  of  sudden  death  immedi- 
ately after  labor  seem  to  be  due  to  the  entrance  of  air  into  the  veins. 
Six  examples  are  cited  by  McClintock  which  were  probably  due  to  this 
cause.  La  Chapelle  relates  two.  An  interesting  case  is  related  by  M. 
Lionet.^  In  this  the  patient  died  five  and  a  half  hours  after  an  easy  and 
natural  labor,  the  chief  symptoms  being  extreme  pallor,  efforts  at  vomit- 
ing, and  dyspnoea.  Air  was  found  in  the  heart  and  in  the  arachnoid 
veins.  There  can  be  no  question  that  the  uterine  sinuses  after  delivery 
are  nearly  as  well  adapted  as  the  veins  of  the  neck  for  allowing  the 
entrance  of  air.  They  are  firmly  attached  to  the  muscular  walls  of  the 
uterus,  so  that  they  gape  open  when  that  organ  is  relaxed,  and  it  is  easy 
to  understand  how  air  might  enter.  Indeed,  in  the  post-mortem  exam- 
ination in  one  of  the  cases  occurring  in  the  practice  of  Mme.  La  Chapeile 
it  is  stated  that  "  the  uterine  sinuses  opened  in  the  interior  of  the  uterus 
by  large  orifices  (one  line  and  a  half  in  diameter),  through  which  air 
could  readily  be  blown  as  far  as  the  iliac  veins,  and  vice  versa."  The 
condition  of  the  uterus  after  delivery  also  enables  the  air  to  have  ready 
access  to  the  mouths  of  the  sinuses,  for  the  alternate  relaxation  and  con- 
traction of  the  uterus  occurring  after  the  placenta  is  expelled  would  tend 
to  draw  in  the  air  as  by  a  suction-pump.  Hence  an  additional  reason 
for  insisting  on  firm  contraction  of  the  uterus,  as  this  will  lessen  the  risk 
of  this  accident. 

Cause  of  Death  in  such  Cases. — The  precise  mechanism  of  death 
from  air  in  the  veins  has  been  a  subject  of  dispute  among  pathologists. 
By  Bichat^  it  was  referred  to  anaemia  and  syncope  from  want  of  blood 
in  the  vessels  of  the  brain,  which  are  occupied  by  air.  Nysten^  attrib- 
uted it  to  distension  of  the  cavities  of  the  heart  by  rarefied  air,  produ- 
cing paralysis  of  its  wail ;  Leroy,  to  a  stoppage  of  the  pulmonary  circu- 
lation, and  consequent  want  of  proper  blood-supply  to  the  left  heart ; 
while  Leroy  d'Etoilles  thought  it  might  depend  on  any  of  these  causes 
or  a  combination  of  all  of  them.  Tliese  and  many  other  hypotheses  on 
the  subject  have  been  advanced,  to  all  of  which  serious  objection  could 
be  raised.  The  most  recent  theory  is  one  maintained  by  Virchow  and 
Oppolzer,^  and  more  recently  by  Feltz,  which  attributes  the  fatal  results 

'  Dehous,  op.  cit.,  p.  58.  ^  Recherches  sur  la  Vie  et  la  Mort,  1 853. 

^  Nysten,  Recherches  de  Phys.  et  Chem.  Path.,  1811. 

*  Casuistics  rffts  Embolies;   Wiener  Med.  Woch.,  1863;  Des  Embolies  capillaire!^,  1868; 
and  op.  cit.,  p.  115. 


PERIPHERAL    VENOUS  THROMBOSIS.  637 

to  impaction  of  the  air-globules  in  the  lesser  divisions  of  the  pulmonary 
arteries,  where  they  form  gaseous  emboli,  and  cause  death  exactly  in  the 
same  way  as  when  the  obstruction  depends  on  a  fibrinous  embolus.  The 
symptoms  observed  in  fatal  cases  closely  correspond  to  those  of  pulmo- 
nary obstruction,  and  it  is  not  unlikely  that  some  cases  attributed  to  other 
causes  may  really  depend  on  the  entrance  of  air  through  the  uterine 
sinuses.  Such,  for  example,  was  most  probably  the  explanation  of  a  case 
referred  to  by  Dr.  Graily  Hewitt  in  a  discussion  dt  the  Obstetrical 
Society.^  Death  occurred  shortly  after  the  removal  of  an  adherent  pla- 
centa, during  which,  no  doubt,  air  could  readily  enter  the  uterine  cavity. 
The  symptoms — viz.  "  severe  pain  in  the  cardiac  region,  distress  as  re- 
gards respiration,  and  pulselessness  " — are  identical  with  those  of  pul- 
monary obstruction.  Dr.  Hewitt  refers  the  death  to  shock,  which  cer- 
tainly does  not  generally  produce  such  phenomena. 


CHAPTER    IX. 


PERIPHEEAL  VENOUS  THROMBOSIS  (SYNS.:  CRUEAL  PHLEBITIS; 
PHLEGMASIA  DOLENS;  ANASARCA  SEROSA;  CEDEMA  LACTEUM ; 
MILK   LEG,  ETC.). 

Peripheral  Thrombosis. — We  now  come  to  discuss  the  symptoms  and 
pathology  of  the  conditions  associated  with  the  formation  of  thrombi  in 
the  peripheral  venous  system,  or  rather  in  the  veins  of  the  lower  extrem- 
ities, since  too  little  is  known  of  their  occurrence  in  other  parts  to  enable 
us  to  say  anything  on  the  subject. 

The  most  important  of  these  is  the  well-known  disease  which  under 
the  name  phlegmasia  dolens  has  attracted  much  attention  and  given  rise 
to  numerous  theories  as  to  its  nature  and  pathology.  In  describing  it 
as  a  local  manifestation  of  a  general  blood-dyscrasia,  and  not  as  an  essen- 
tial local  disease,  I  am  making  an  assumption  as  to  its  pathology  that 
many  eminent  authorities  would  not  consider  justifiable.  I  have,  how- 
ever, already  stated  some  of  the  reasons  for  so  doing,  and  I  shall  shortly 
hope  to  show  that  this  view  is  not  incompatible  with  the  most  probable 
explanation  of  the  peculiar  state  of  the  affected  limb. 

Symptoms. — The  first  symptom  which  usually  attracts  attention  is 
severe  pain  in  some  part  of  the  limb  that  is  about  to  be  affected.  The 
character  of  the  pain  varies  in  different  cases.  In  some  it  is  extremely 
acute,  and  is  most  felt  in  the  neighborhood  and  along  the  course  of  the 
cliicf  venous  trunks.  It  may  begin  in  the  groin  or  hip  and  extend 
downward,  or  it  may  commence  in  the  calf  and  proceed  upward  toward 
the  pelvis.  The  pain  abates  somewhat  after  swelling  of  the  limb  (which 
generally  begins  within  twenty-four  hours),  but  it  is  always  a  distressing 
symptom,  and  continues  as  long  as  the  acute  stage  of  the  disease  lasts. 

*  Obslet.  Trans.,  vol.  x.  p.  28. 


638  THE  PUERPERAL  STATE. 

The  restlessness,  want  of  sleep,  and  snifering  which  it  produces  are  some- 
times excessive.  Coincident  with  the  pain,  and  sometimes  preceding  it, 
more  or  less  malaise  is  experienced.  The  patient  may  for  a  day  or  two 
be  restless,  irritable,  and  out  of  sorts  without  any  very  definite  cause, 
or  the  disease  may  be  ushered  in  by  a  distinct  rigor.  Generally,  there 
is  constitutional  disturbance,  varying  with  the  intensity  of  the  case.  The 
pulse  is  rapid  and  weak,  120  or  thereabouts  ;  the  temperature  elevated 
from  101°  to  102°,  with  an  evening  exacerbation.  The  patient  is  thirsty, 
the  tongue  glazed  or  Avhite  and  loaded,  the  bowels  are  constipated.  In 
some  few  cases,  when  the  local  affection  is  slight,  none  of  these  constitu- 
tional symptoms  are  observed. 

Condition  of  the  Affected  Limb. — The  characteristic  swelling  rapidly 
follows  the  commencement  of  the  symptoms.  It  generally  begins  in  the 
groin,  whence  it  extends  downward.  It  may  be  limited  to  the  thigh,  or 
the  whole  limb,  even  to  the  feet,  may  be  implicated.  More  rarely  it  com- 
mences in  the  calf  of  the  leg,  extending  upward  to  the  thigh  and  down- 
ward to  the  feet.  The  affected  parts  have  a  peculiar  appearance  which 
is  pathognomonic  of  the  disease.  They  are  hard,_tense,  and  brawny,  of 
a  shiny  white  color^^d  jiot^yielding^jyi^^  except  toward  the 

beginnmglnKrend  of  the  illness.  The  appearances  presented  are  quite 
different  from  those  of  ordinary  oedema.  When  the  whole  thigh  is 
affected  the  limb  is  enormously  increased  in  size.  Frequently  the  ven- 
ous trunks,  especially  the  femoral  and  popliteal  veins,  are  felt  obstructed 
with  coagula,  and  rolling  under  the  finger.  They  are  painful  when 
handled,  and  in  their  course  more  or  less  redness  is  occasionally  observed. 
Either  leg  may  be  attacked,  but  the  left  more  frequently  than  the  right. 
There  is  a  marked  tendency  for  the  disease  to  spread,  and  we  often  find, 
in  a  case  which  is  progressing  apparently  well,  a  rise  of  temperature  and 
an  accession  of  febrile  symj^toms  followed  by  the  swelling  of  the  other 
limb. 

Progress  of  the  Disease. — After  the  acute  stage  has  lasted  from  a  week 
to  a  fortnight  the  constitutional  disturbance  becomes  less  marked,  the 
pulse  and  temperature  fall,  the  pain  abates,  and  the  sleeplessness  and 
restlessness  are  less.  The  swelling  and  tension  of  the  limb  now  begin 
to  diminish,  and  absorption  commences.  This  is  invariably  a  slow  process. 
It  is  always  many  ^veeks  before  the  effusion  has  disappeared,  and  it  may 
be  many  months.  The  limb  retains  for  a  length  of  time  the  peculiar 
ivooden  feeling,  as  Dr.  Churchill  terms  it.  Any  imprudence,  such  as  a 
too  early  attempt  at  walking,  may  bring  on  a  relapse  and  fresh  swelling 
of  the  limb.  This  gradual  recovery  is  by  far  the  most  common  termi- 
nation of  the  disease.  In  some  rare  cases  suppuration  may  take  place, 
either  in  the  subcutaneous  cellular  tissue,  the  lymphatic  glands,  or  even 
in  the  joints,  and  death  may  result  from  exhaustion.  The  possibility 
of  pulmonary  obstruction  and  sudden  death  from  separation  of  an  em- 
bolus have  already  been  pointed  out ;  and  the  fact  that  this  lamentable 
occurrence  has  generally  followed  some  undue  exertion  should  be  borne 
in  mind  as  a  guide  in  the  management  of  our  patient. 

Period  of  Commencement. — The  disease  usually  begins  within  a  short 
time  after  delivery,  rarely  before  the  second  week.  In  22  cases  tabu- 
lated by  Dr.  Robert  Lee,  7  w^ere  attacked  between  the  fourth  and  twelfth 


PERIPHERAL    VENOUS  THROMBOSIS.  639 

days,  and  14  after  the  second  week.  Some  cases  have  been  described  as 
commencing  even  months  after  delivery.  It  is  questionable  if  these  can  i 
be  classed  as  puerperal,  for  it  must  not  be  forgotten  that  phlegmasia 
dolens  is  by  no  means  necessarily  a  puerperal  disease  [or  confined  to  the 
female  sex].  There  are  many  other  conditions  which  may  give  rise  to 
it,  all  of  them,  however,  such  as  produce  a  septic  and  hyperinosed  state 
of  the  blood,  such  as  malignant  disease,  dysentery,  phthisis,  and  the 
like.  My  own  experience  would  lead  me  to  think  that  cases  of  this 
kind  are  much  more  common  than  is  generally  believed. 

History  and  Pathology. — The  disease  has  long  attracted  the  attention 
of  the  profession.  Passing  over  more  or  less  obscure  notices  by  Hippoc- 
rates, De  Castro,  and  others,  we  find  the  first  clear  account  in  the  writ- 
ings of  ^lauriceau,  who  not  only  gave  a  very  accurate  description  of  its 
symptoms,  but  made  a  guess  at  its  pathology  which  was  certainly  more 
happy  than  the  speculations  of  his  successors  :  it  is,  he  says,  caused  "  by 
a  reflux  on  the  parts  of  certain  humors  Avhich  ought  to  have  been  evacu- 
ated by  the  lochia."  Puzos  ascribed  it  to  the  arrest  of  the  secretion  of 
milk  and  its  extravasation  in  the  affected  limb.  This  theory,  adopted 
by  Levret  and  many  subsequent  writers,  took  a  strong  hold  on  both 
professional  and  public  opinion,  and  to  it  we  owe  many  of  the  names  by 
which  the  disease  is  known  to  this  day,  such  as  oedema  lacteum,  milk 
leg,  etc.  In  1784,  Mr.  White  of  Manchester  attributed  it  to  some  mor- 
bid condition  of  the  lymphatic  glands  and  vessels  of  the  aifected  parts ; 
and  this  or  some  analogous  theory,  such  as  that  of  rupture  of  the 
lymphatics  crossing  the  pelvic  brim,  as  maintained  by  Tyre  of  Glou- 
cester, or  general  inflammation  of  the  absorbents,  as  held  by  Dr.  Ferrier, 
was  generally  adopted. 

Phlebitic  Theory. — It  was  not  until  the  year  1823  that  attention  was 
drawn  to  the  condition  of  the  veins.  To  Bouilla?ud  belongs  the  un- 
doubted merit  of  first  pointing  out  that  the  veins  of  the  affected  limb 
were  blocked  up  by  coagula,  although  the  fact  had  been  previously 
observed  by  Dr.  Davis  of  University  College.  Dr.  Davis  made  dissec- 
tions of  the.  veins  in  a  fatal  case,  and  found,  as  Bouillaud  had  done,  that 
they  were  filled  with  coagula,  which  he  assumed  to  be  the  results  of 
inflammation  of  their  coats ;  hence  the  name  of  "  crural  phlebitis  "  which 
has  been  extensively  adopted  instead  of  phlegmasia  dolens.  Dr.  Robert 
Lee  did  much  to  favor  this  view,  and,  finding  that  thrombi  were  present 
in  the  iliac  and  uterine  as  well  as  in  the  femoral  veins,  he  concluded 
that  tlie  phlebitis  commenced  in  the  uterine  branches  of  the  hypogastric 
veins  and  extended  downward  to  the  femorals.  He  pointed  out  that 
phlegmasia  dolens  was  not  limited  to  the  puerperal  state,  but  that,  when 
it  did  occur  independently  of  it,  other  causes  of  uterine  phlebitis  were 
present,  such  as  cancer  of  the  os  and  cervix  uteri.  The  infliunmatory 
theory  Avas  pretty  generally  received,  and  even  now  is  considered  by 
many  to  be  a  sufficient  explanation  of  the  disease.  Indeed,  the  fact  that 
more  or  less  thrombosis  was  always  present  could  not  be  dcmiod  ;  and  on 
the  supposition  that  thrombosis  could  only  be  caused  by  j)l)lebitis,  as  was 
long  suj)poscd  to  be  the  case,  the  inflammatory  tlicory  was  the  natural 
one.  Before  long,  however,  pathologists  pointed  out  that  thrf)inbosis 
was  by  no  means  necessarily,  or  even  generally,  the  result  of  inflamma- 


640  THE  PUERPERAL  STATE. 

tion  of  the  vessels  in  which  the  clot  was  contained,  but  that  the  inflam- 
mation was  more  generally  the  result  of  the  coagulura. 

Theory  of  its  Dependence  on  Septic  Causes. — The  late  Dr.  Mackenzie 
took  a  prominent  part  in  o])posing  the  phlebitic  theory.  He  proved  by 
numerous  experiments  on  the  lower  animals  that  inflammation  is  not 
sufficient  of  itself  to  produce  the  extensive  thrombi  which  are  found  to 
exist,  and  that  inflammation  originating  in  one  part  of  a  vein  is  not  apt 
to  spread  along  its  canal,  as  the  phlebitic  theory  assumes.  His  con- 
clusion is,  that  the  origin  of  the  disease  is  rather  to  be  sought  in  some 
septic  or  altered  condition  of  the  blood  producing  coagulation  in  the 
veins.  Dr.  Tyler  Smith  ^  pointed  out  an  occasional  analogy  between  the 
causes  of  phlegmasia  clolens  and  puerperal  fever,  evidently  recognizing 
the  dependence  of  the  former  on  blood-dyscrasia.  "  I  believe,"  he  says, 
"  that  contagion  and  infection  play  a  very  important  part  in  the  produc- 
tion of  the  disease.  I  look  on  a  w^oman  attacked  with  phlegmasia 
dolens  as  having  made  a  fortunate  escape  from  the  greater  dangers  of 
difliise  phlebitis  or  puerperal  fever."  In  illustration  of  this  he  narrates 
the  following  instructive  history  :  "A  short  time  ago  a  friend  of  mine 
had  been  in  close  attendance  on  a  patient  dying  of  erysipelatous  sore 
throat  with  sloughing,  and  was  himself  aflected  with  sore  throat.  Under 
these  circumstances  he  attended,  within  the  space  of  twenty-four  hours, 
three  ladies  in  their  confinements,  all  of  whom  were  attacked  with  phleg- 
masia dolens." 

View  of  Tilbury  Fox. — The  latest  important  contribution  to  the 
pathology  of  the  disease  is  contained  in  two  papers  by  Dr.  Tilbury  Fox, 
published  in  the  second  volume  of  the  Obstetrical  Transactions.  He 
maintained  that  something  beyond  the  mere  presence  of  coagula  in  the 
veins  is  required  to  produce  the  phenomena  of  the  disease,  although  he 
admitted  that  to  be  an  important,  and  even  an  essential,  part  of  the 
pathological  changes  present.  The  thrombi  he  believed  to  be  produced 
either  by  extrinsic  or  intrinsic  causes — the  former  comprising  all  cases 
of  pressure  by  tumor  or  the  like ;  the  latter,  and  the  most  important, 
being  divisible  into  the  heads  of — 

1.  True  inflammatory  changes  in  the  vessels,  as  seen  in  the  epidemic 
form  of  the  disease. 

2.  Simple  thrombus,  produced  by  rapid  absorption  of  morbid  fluid. 

3.  Virus  action  and  thrombus  conjoined,  the  phlegmasia  dolens  itself 
being  the  result  of  simple  thrombus,  and  not  produced  by  diseased  (in- 
flamed) coats  of  vessels ;  the  general  symptoms  the  result  of  the  general 
blood-state. 

He  further  pointed  out  that  the  peculiar  swelling  of  the  limbs  cannot 
be  explained  by  the  mere  presence  of  oedema,  from  which  it  is  essentially 
difi^erent ;  the  white  appearance  of  the  skin,  the  severe  neuralgic  pain, 
and  the  persistent  numbness  indicating  that  the  whole  of  the  cutaneous 
textures,  the  cutis  vera,  and  even  the  epithelial  layer,  are  infiltrated  with 
fibrinous  deposit.  He  concluded,  therefore,  that  the  swelling  is  the 
result  of  oedema  plus  something  else,  that  something  being  obstruction 
of  the  lymphatics,  by  wdiich  the  absorption  of  efl'used  serum  is  prevented. 
The  efficient  cause  which  produces  these  changes  he  believes  to  be,  in  the 

'  Tylei-  Smith,  Manual  of  Obstetrics,  p.  538. 


PERIPHERAL    VENOUS  THROMBOSIS.  641 

majority  of  cases,  a  septic  action  originating  in  the  uterus,  producing  a 
condition  similar  to  that  in  which  phlegmasia  dolens  arises  in  the  non- 
puerperal state. 

There  is  no  doubt  much  force  in  Dr.  Fox's  arguments,  and  it  may,  I 
think,  be  conceded  that  obstruction  of  the  veins,  per  se,  is  not  sufficient 
to  produce  the  peculiar  appearance  of  the  limb.  It  is,  moreover,  certain 
that  phlebitis  alone  is  also  an  insufficient  explanation  not  only  of  the 
symptoms,  but  even  of  the  presence  of  thrombi  so  extensive  as  those 
that  are  found.  The  view  which  traces  the  disease  solely  to  inflamma- 
tion or  obstruction  of  lymphatics  is  purely  theoretical,  has  no  basis  of 
facts  to  support  it,  and  finds  now-a-days  no  supporters.  The  experi- 
ments of  Mackenzie  and  Lee,  as  well  as  the  vastly  increased  knowledge 
of  the  causes  of  thrombosis  which  the  researches  of  modern  pathologists 
have  given  us,  seem  to  jDoint  strongly  to  the  view  already  stated,  that 
the  disease  can  only  be  explained  by  a  general  blood-dyscrasia  depending 
on  the  puerperal  state.  It  by  no  means  follows  that  we  are  to  consider 
Dr.  Fox's  speculations  as  incorrect.  It  is  far  from  improbable  that  the 
lymphatic  vessels  are  implicated  in  the  production  of  the  peculiar  swell- 
ing, only  we  are  not  as  yet  in  a  position  to  prove  it.  There  is  no  inhe- 
rent improbability  in  the  supposition  that  the  same  morbid  state  of  the 
blood  which  produces  thrombosis  in  the  veins  may  also  give  rise  to  such 
an  amount  of  irritation  in  the  lymphatics  as  may  interfere  with  their 
functions,  and  even  obstruct  them  altogether.  The  essential  and  all- 
important  pj)int  in  the  pathology  of  the  disease,  Tiowever,  ^eems^jin- 
doubtedly^to  be  thrombosis  in  the  veins  ;  and  the  probability  of  there 
Ijemg^some  as  yet  undetermined  pathological  changes  in  addition  to  this 
by  no  means  militates  against  the  view  I  have  taken  of  the  intimate 
connection  of  the  disease  with  other  results  of  thrombosis  in  different 
vessels. 

Changes  occurring  in  the  Thrombi. — The  changes  which  take  place  in 
the  thrombi  all  tend  to  their  ultimate  absorption.  These  have  been 
described  by  various  authors  as  leading  to  organization  or  suppuration. 
It  is  probable,  however,  that  the  appearances  which  have  led  to  such  a 
supposition  are  fallacious,  and  that  they  are  really  due  to  retrograde 
metamorphosis  of  the  fibrin,  generally  of  an  amylaceous  or  fatty  cha- 
racter. 

iJetachment  of  Emboli. — The  peculiarities  of  a  clot  that  most  favor 
detachment  of  an  embolus  are  such  a  shape  as  admits  of  a  portion  float- 
ing freely  in  the  l^lood-current,  by  the  force  of  which  it  is  detached  and 
carried  to  -its  ultimate  destination.  When  the  accident  has  occurred  it  is 
often  possible  to  recognize  the  peripheral  thrombus  from  which  the  em- 
bolus has  separated,  by  the  fact  of  its  terminal  extremity  presenting  a 
fresh ]y-fractu red  end,  instead  of  the  rounded  head  natural  to  it.  Such 
detacliment  is  unlikely  to  occur,  even  when  favored  by  the  sluipe  of  tlie 
dot,  unless  sufficient  time  have  elapsed  after  its  formation  to  aduiit  of 
its  softening  and  becoming  Itrittle.  Tlie  curious  fact  1  have  before  men- 
tioned, of"  true  puerperal  eml^olism  occurring  in  the  large  majority  of 
cases  only  after  the  nineteenth  day  from  dehvery,  finds  a  ready  explana- 
tion in  this  theory,  wliicli  it  rcjmarkably  corrol)oi'ates. 

Trcat'nient. — On  the  sii})position  that  ])ldegmasia  dolens  was  tlie  result 

41 


642  THE  PUERPERAL  STATE. 

of  inflammation  of  the  veins  of  the  affected  limb,  an  antiphlogistic  course 
of  treatment  was  naturally  adopted.  Accordingly,  most  writers  on  the 
subject  recommend  depletion,  generally  by  the  application  of  leeches 
along  the  course  of  the  affected  vessels.  We  are  told  that  if  the  pain 
continue  the  leeches  should  be  applied  a  second  or  even  a  third  time. 
If  we  admit  the  septic  origin  of  the  disease,  we  must,  I  think,  see  the 
impropriety  of  such  a  practice.  The  fact  that  it  occurs  in  a  large  major- 
ity of  cases  in  patients  of  a  weakly  and  debilitated  constitution,  often  in 
women  who  have  suffered  from  hemorrhage,  is  a  further  reason  for  not 
adopting  this  routine  custom.  If  local  loss  of  blood  be  used  at  all,  it 
should  be  strictly  limited  to  cases  in  which  there  is  much  tenderness  and 
redness  across  the  course  of  the  veins,  and  then  only  in  patients  of 
plethoric  habits  and  strong  constitution.  Cases  of  this  kind  will  form 
a  very  small  minority  of  those  coming  under  our  observation. 

Over-active  Treatment  Unadvisable. — What  has  been  said  of  the  path- 
ology of  the  affection  tends  to  the  conclusion  that  active  treatment  of 
J  any  kind  in  the  hope  of  curing  the  disease  is  likely  to  be  useless.  Our 
chief  reliance  must  be  on  time  and  perfect  rest,  in  order  to  admit  of  the 
thrombi  and  the  secondary  effusion  being  absorbed,  while  we  relieve 
the  pain  and  other  prominent  symptoms  and  support  the  strength  and 
improve  the  constitution  of  the  patient. 

Relief  of  Pain,  etc. — The  constant  application  of  heat  and  moisture  to 
the  affected  limb  will  do  much  to  lessen  the  tension  and  pain.     Wrap- 
ping the  entire  limb  in  linseed-meal  poultices,  frequently  changed,  is  one 
of  the  best  means  of  meeting  this  indication.     If,  as  is  sometimes  the 
,  case,  the  weight  of  the  poultices  be  too  great  to  be  readily  borne,  we 
^^^^  >     jmay  substitute  warm  flannel  stupes  covered  with  oiled  silk.     Local 
■**i  ''anodyne  applications  afford  much  relief,  and  may  be  advantageously 

used  along  with  the  poultices  and  stupes,  either  by  sprinkling  their  sur- 
face freely  with  laudanum  or  chloroform  and  belladonna  liniment,  or 
by  soaking  the  flannels  in  poppy-head  fomentations.  It  is  needless  to 
say  that  the  mosj^absolutejgstjiLbgd  should  be  enjoined,  even  in  slight 
cases,  and  that  the  limb  should  be  effectually  guarded  from  undue  pres- 
sure by  a  cradle  or  some  similar  contrivance.  Local  counter-irritation 
has  been  strongly  recommended,  and  frequent  blisters  have  been  consid- 
ered by  some  to  be  almost  specific.  I  should  myself  hesitate  to  use 
blisters,  as  they  certainly  Avould  not  be  soothing  applications,  and  one 
hardly  sees  how  they  can  be  of  much  service  in  hastening  the  absorption 
of  the  effusion. 

Constitutional  Treatment. — During  the  acute  stage  of  the  disease  the 
constitutional  treatment  must  be  regulated  by  the  condition  of  the  pa- 
tient. Light  but  nutritious  diet  must  be  administered  in  abundance, 
such  as  milk,  beef-tea,  and  soups.  Should  there  be  much  debility,  stim- 
ulants in  moderation  may  prove  of  service.  With  regard  to  medicines, 
we  shall  probably  find  benefit  from  such  as  are  calculated  to  improve 
the  condition  of  the  blood  and  the  general  health  of  the  patient.  Chlo- 
rate of  potash,  with  diluted  hydrochloric  acid,  quinine,  either  alone  or 
in  combination  with  sesquicarbonate  of  ammonia,  the  tincture  of  the 
perchloride  of  iron,  are  the  drugs  that  are  most  likely  to  prove  of  ser- 
vice.    Alkalies  and  other  medicines,  which  have  been  recommended  in 


PEBIPHEBAL    VENOUS  THROMBOSIS.  643 

the  hope  of  hastening  the  absorption  of  coagula,  must  be  considered  as 
altogether  useless.  Pain  must  be  relieved  and  sleep  procured  by  the 
judicious  use  of  anodynes,  such  as  Dover's  powder,  the  subcutaneous 
injection  of  morphia,  or  chloral.  Generally,  no  form  answers  so  well 
as  the  hypodermic  injection  of  morphia. 

Subsequent  Local  Treatment. — When  the  acute  symptoms  have  abated 
and  the  temperature  has  fallen,  the  poultices  and  stupes  may  be  discon- 
tinued and  the  limb  swathed  in  a  flannel  roller  from  the  toes  upward. 
The  equable  pressure  and  support  thus  afforded  materially  aid  the 
absorption  of  the  effusion  and  tend  to  diminish  the  size  of  the  limb. 
At  a  still  later  stage  very  gentle  inunctions  of  weak  iodine  ointment 
may  be  used  with  advantage  once  a  day  before  the  roller  is  applied. 
Shampooing  and  friction  of  the  limb,  generally  recommended  for  the 
purpose  of  hastening  absorption,  should  be  carefully  avoided,  on  account 
of  the  possible  risk  of  detaching  a  portion  of  the  coagulum  and  produ- 
cing embolism.  This  is  no  merely  imaginary  danger,  as  the  following 
fact  narrated  by  Trousseau  proves :  "A  phlegmasia  alba  dolens  had 
appeared  on  the  left  side  in  a  young  woman  suffering  from  peri-uterine 
phlegmon.  The  pain  having  ceased,  a  thickened  venous  trunk  was  felt 
on  the  upper  and  internal  part  of  the  thigh,  Rather  strong  pressure 
was  being  made,  when  M.  Demarquay  felt  something  yield  under  his 
fingers.  A  few  minutes  afterward  the  patient  was  attacked  with  dread- 
ful palpitation,  tumultuous  cardiac  action,  and  extreme  pallor,  and  death 
was  believed  to  be  imminent.  After  some  hours,  however,  the  oppres- 
sion ceased,  and  the  patient  eventually  recovered.  A  slightly-attached 
coagulum  must  have  become  separated  and  conveyed  to  the  heart  or 
pulmonary  artery."  ^  Warm  douches  of  water — of  salt  water,  if  it  can 
be  obtained — may  be  advantageously  used  in  the  later  stages  of  the  dis- 
ease, and  they  may  be  applied  night  and  morning,  the  limb  being  band- 
aged in  the  interval.  The  occasional  use  of  the  electric  current  is  said 
to  promote  absorption,  and  it  would  seem  likely  to  be  a  serviceable 
remedy. 

Change  of  Air,  etc. — When  the  patient  is  well  enough  to  be  moved 
a  change  of  air  to  the  seaside  will  be  of  value.  Great  caution,  however,  \ 
should  be  recommended  in  using  the  limb,  and  it  is  far  better  not  to  run 
the  risk  of  a  relapse  by  any  undue  haste  in  this  respect.  It  is  well  to 
\\^arn  the  patient  and  her  friends  that  a  considerable  time  must  of  neces- 
sity elapse  before  the  local  signs  of  the  disease  have  completely  disap- 
peared. , 

^  Trousseau,  "Clinique  de  I'Hotel  Dien,"  in  Gaz.  des  Hop.,  1860,  p.  577. 


644  THE  PUERPERAL  STATE. 


CHAPTER   X. 

PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS. 

Feoim  the  earliest  time  the  occurrence  after  parturition  of  severe  forms 
of  inflammatory  disease  in  and  about  the  pelvis,  frequently  ending  in  sup- 
puration, has  been  well  known.  It  is  only  of  late  years,  however,  that 
these  diseases  have  been  made  the  subject  of  accurate  clinical  and  patho- 
logical investigation,  and  that  their  true  nature  has  begun  to  be  under- 
stood. Nor  is  our  knowledge  of  them  as  yet  by  any  means  complete. 
They  merit  careful  study  on  the  part  of  the  accoucheur,  for  they  give 
rise  to  some  of  the  most  severe  ancl  protracted  illnesses  from  which  jauer- 
peral  patients  suffer.  They  are  often  obscure  in  their  origin  and  apt  to 
be  overlooked,  and  they  not  rarely  leave  behind  them  lasting  mischief. 

These  diseases  are  not  limited  to  the  puerperal  state.  On  the  contrary, 
many  of  the  severest  cases  arise  from  causes  altogether  unconnected  with 
childbearing.  These  will  not  be  now  considered,  and  this  chai^ter  deals 
solely  with  such  forms  as  may  be  directly  traced  to  childbirth. 

Two  Distinct  Forms. — Modern  researches  have  demonstrated  that 
there  are  two  distinct  varieties  of  inflammatory  disease  met  with  after 
labor,  which  difler  materially  from  each  other  in  many  respects.  In  one 
of  these  the  inflammation  aiFects  chiefly  the  connective  tissue  surround- 
ing the  generative  organs  contained  within  the  pelvis,  or  extends  up 
from  beneath  the  peritoneum  and  into  the  iliac  fossae.  In  the  other  it 
attacks  that  portion  of  the  peritoneum  which  covers  the  pelvic  viscera, 
and  is  limited  to  it. 

So  much  is  admitted  by  all  writers,  but  great  obscurity  in  description, 
and  consequent  difficulty  in  understanding  satisfactorily  the  nature  of 
these  affections,  have  resulted  from  the  variety  of  nomenclature  which 
different  authors  have  adopted. 

Thus,  the  former  disease  has  been  variously  described  as  pelvic  cellu- 
litis, peri-uterine  phlegmon,  parametritis,  or  pelvic  ahscess ;  while  the 
latter  is  not  unfrequently  called  perimetritis,  as  contradistinguished  from 
parametritis.  The  use  of  the  prefix  jmra  or  peri  to  distinguish  the  cel- 
lular or  peritoneal  variety  of  inflammation,  originally  suggested  by  Vir- 
chow,  has  been  pretty  generally  adopted  in  Germany,  and  has  been 
strongly  advocated  in  this  country  by  Matthe^^'S  Duncan.  It  has  never, 
however,  found  much  favor  with  English  writers,  and  the  similarity  of 
the  two  names  is  so  great  as  to  lead  to  confusion.  I  have  therefore 
selected  the  terms  " pelvic  jm-itonit is"  and  "pelvic  cellulitis,''  as  convey- 
ing in  themselves  a  fairly  accurate  notion  of  the  tissues  mainly  involved. 

Importance  of  Distinguishing  the  Two  Classes  of  Cases. — The  import- 
ant fact  to  remember  is  that  there  exist  two  distinct  varieties  of  inflam- 
matory disease,  presenting  many  similarities  in  their  com'se,  symptoms, 
and  results,  often  occurring  simultaneously,  but  in  the  main  distinct  in 
their  pathology  and  capable  of  being  differentiated.     Thomas  compares 


PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS.  645 

them — and,  as  serving  to  fix  the  facts  on  the  memory,  the  illustration  is 
a  good  one — to  pleurisy  and  pneumonia.  "  Like  them,"  he  says,  "  they 
are  separate  and  distinct,  like  them  affect  different  kinds  of  structure, 
and  like  them  they  generally  complicate  each  other."  It  might  there- 
fore be  advisable,  as  most  writers  on  the  disease  occurring  in  the  non- 
puerperal state  have  done,  to  treat  of  them  in  two  separate  chapters. 
There  is,  however,  more  difficulty  in  distinguishing  them  as  puerperal 
than  as  non-puerperal  affections,  for  which  reason,  as  well  as  for  the  sake 
of  brevity,  I  think  it  better  to  consider  them  together,  pointing  out  as 
I  proceed  the  distinctive  peculiarities  of  each. 

Seat  of  Disease. — When  attention  was  first  directed  to  this  class  of 
diseases  the  pelvic  cellular  tissue  was  believed  to  be  the  only  structure 
affected.  This  was  the  view  maintained  by  Nonat,  Simpson,  and  many 
modern  writers.  Attention  was  first  prominently  directed  to  the  import- 
ance of  localized  inflammation  of  the  peritoneum,  and  to  the  fact  that 
many  of  the  supposed  cases  of  cellulitis  were  really  peritonitic,  by  Ber- 
nutz.  There  can  be  no  doubt  that  he  here  made  an  enormous  step  in 
advance.  Like  many  authors,  however,  he  rode  his  hobby  a  little  too 
hard,  and  he  erred  in  denying  the  occurrence  of  cellulitis  in  many  cases 
in  which  it  undoubtedly  exists. 

Etiology. — The  great  influence  of  childbirth  in  producing  these  dis- 
eases has  long  been  fully  recognized.  Courty  estimates  that  about  two- 
thirds  of  all  the  cases  met  with  occur  in  connection  with  delivery  or 
abortion,  and  Duncan  found  that,  out  of  40  carefully-observed  cases,  25 
were  associated  with  the  puerperal  state. 

The  Inflammation  is  Secondary,  and  never  Idiopathie. — It  is  pretty  gen-  j 
erally  admitted  by  most  modern  writers  that  both  varieties  of  the  dis-  \ 
ease  are  produced  by  the  extension  of  inflammation  from  either  the  ute-  ' 
rus,  the  Fallopian  tubes,  or  the  ovaries.     This  point  has  been  especially 
insisted  on  by  Duncan,  who  maintains  that  the  disease  is  never  idiopathic, 
and  is  "  invariably  secondary  either  to  mechanical  injury,  or  to  the  ex- 
tension of  inflammation  of  some  of  the  pelvic  viscera,  or  to  the  irrita- 
tion of  the  noxious  discharges  through  or  from  the  tubes  or  ovaries." 

Often  Intimately  connected  toith  Septiccemia. — Their  intimate  connec- 
tion with  puerperal  septicsemia  is  also  a  prominent  fact  in  the  natural 
history  of  the  diseases.  Barker  mentions  a  curious  observation  illus- 
trative of  this,  that  when  puerperal  fever  is  endemic  in  the  Bellevue 
Hospital  in  New  York  cases  of  pelvic  peritonitis  and  cellulitis  are  also 
invariably  met  with.  Olshausen  has  also  remarked  that  in  the  Ly- 
ing-in Plospital  at  Halle  during  the  autumn  vacation,  when  the  pa- 
tients arc  not  attended  by  practitioners,  and  when,  therefore,  the 
clian(;e  of  septic  infection  being  conveyed  to  them  is  less,  these  inilam- 
mations  are  almost  always  absent.  As  inflammation  of  the  lining  mem- 
brane of  the  uterus,  of  the  vaginal  mucous  membrane,  and  of  the  pelvic 
foiHKtctive  tissue  are  of  very  constant  occurrence  as  local  phenomena  of 
Kcj)ti(;  absor|)tion,  the  connection  between  the  two  classes  of  cases  is 
readily  susceptible;  of  explanation.  Schroeder,  indeed,  goes  farther, 
and  in<;ludcs  his  d(;scription  of  these  diseases  under  the  head  of  pucr- 
p(;ral  fever.  Tliey  do  not,  however,  necessarily  depend  u|)()n  it;  foi', 
altliough  it  must  he  admitted  that  cases  of  tiiis  kind  fi)rni  a  large  pro- 


646  THE  PUERPERAL  STATE. 

portion  of  those  met  with,  others  unquestionably  occur  which  cannot  be 
traced  to  such  sources,  but  are  the  direct  result  of  causes  altogether  un- 
connected with  the  inflammation  attending  on  septic  absorption,  such  as 
undue  exertion  shortly  after  delivery  or  premature  coition.  Mechanical 
causes  may  beyond  doubt  excite  the  disease  in  a  woman  predisposed  by 
the  puerperal  process,  but  they  cannot  fairly  be  included  under  the  head 
of  puerperal  fever. 

Seat  of  the  Inflammation  in  Pelvic  Cellulitis. — Abundance  of  areolar 
tissue  exists  in  connection  with  the  pelvic  viscera  which  may  be  the  seat 
of  cellulitis.  It  forms  a  loose  padding  between  the  organs  contained  in 
the  pelvis  proper,  surrounds  the  vagina,  the  rectum,  and  the  bladder,  and 
is  found  in  considerable  quantity  between  the  folds  of  the  broad  ligaments. 
From  these  parts  it  extends  upward  to  the  iliac  fossse  and  the  inner  sur- 
face of  the  abdominal  parietes.  In  any  of  these  positions  it  may  be  the 
seat  of  the  kind  of  inflammation  we  are  discussing.  The  essential  cha- 
racter of  the  inflammation  is  similar  to  that  which  accompanies  areolar 
inflammation  in  other  parts  of  the  body.  There  is  first  an  acute  inflam- 
matory oedema,  followed  by  the  infiltration  of  the  areolae  of  the  connec- 
tive tissue  with  exudation,  and  the  consequent  formation  of  appreciable 
swellings.  These  may  form  in  any  part  of  the  pelvis.  Thus,  we  may 
meet  with  them — and  this  is  a  very  common  situation — between  the 
folds  of  the  broad  ligaments,  forming  distinct  hard  tumors  connected 
with  the  uterus  and  extending  to  the  pelvic  walls,  their  rounded  outlines 
being  readily  made  out  by  bi-manual  examination.  If  the  cellulitis  be 
limited  in  extent,  such  a  swelling  may  exist  on  one  side  of  the  uterus 
only,  forming  a  rounded  mass  of  varying  size  and  apparently  attached  to 
it.  At  other  times  the  exudation  is  more  extensive,  and  may  completely 
or  partially  surround  the  uterus,  extending  to  the  cellular  tissue  between 
the  vagina  and  rectum  or  between  the  uterus  and  the  bladder.  In  such 
cases  the  uterus  is  imbedded  and  firmly  fixed  in  dense,  hard  exudation. 
At  other  times  the  inflammation  chiefly  aflects  the  cellular  tissue  cover- 
ing the  muscles  lining  the  iliac  fossae.  There  it  forms  a  mass,  easily 
made  out  by  palpation,  but  on  vaginal  examination  little  or  no  trace  of 
the  exudation  can  be  felt,  or  only  a  sense  of  thickness  at  the  roof  of  the 
vagina  on  the  same  side  as  the  swelling. 

Seat  of  the  Inflammation  in  Pelvic  Peritonitis. — In  pelvic  peritonitis 
the  inflammation  is  limited  to  that  portion  of  the  peritoneum  which 
invests  the  pelvic  viscera.  Its  extent  necessarily  varies  with  the  intens- 
ity and  duration  of  the  attack.  In  some  cases  there  may  be  little  more 
than  irritation,  while  more  often  it  runs  on  to  exudation  of  plastic  mate- 
rial. The  result  is  generally  complete  fixation  of  the  uterus  and  hard- 
ening and  swelling  in  the  roof  of  the  vagina,  and  the  lymph  poured  out 
may  mat  together  the  surrounding  viscera,  so  as  to  form  swellings  diffi- 
cult, in  some  cases,  to  differentiate  from  those  resulting  from  cellulitis. 
On  post-mortem  examination  the  pelvic  viscera  are  found  extensively 
adherent,  and  the  agglutination  may  involve  the  coils  of  the  intestine  in 
the  vicinity,  so  as  sometimes  to  form  tumors  of  considerable  size. 

Relative  Frequency  of  the  Two  Forms  of  Disease. — The  relative  fre- 
quency of  these  two  forms  of  inflammation  as  puerperal  affections  is  not 
easy  to  ascertain.     In  the  non-puerperal  state  the  peritonitic  variety  is 


PELVIO  CELLULITIS  AND  PELVIC  PERITONITIS.  647 

much  the  more  common,  but  in  the  puerperal  state  they  very  generally 
complicate  each  other,  and  it  is  rare  for  cellulitis  to  exist  to  any  great 
extent  without  more  or  less  peritonitis. 

8ym2itomatology. — The  earliest  symptom  is  pain  in  the  lower  part  of 
the  abdomen,  which  is  generally  preceded  by  rigor  or  chilliness.  The 
amount  of  pain  varies  much.  Sometimes  it  is  comparatively  slight,  and 
it  is  by  no  means  rare  to  meet  with  patients,  the  subjects  of  very  consid- 
erable exudations,  who  suiFer  little  more  than  a  certain  sense  of  weight 
and  discomfort  at  the  lower  part  of  the  abdomen.  On  the  other  hand, 
the  suffering  may  be  excessive,  and  is  characterized  by  paroxysmal 
exacerbations,  the  patient  being  comparatively  free  from  pain  for  several 
successive  hours,  and  then  having  attacks  of  the  most  acute  agony. 
Schroeder  says  that  pain  is  always  a  symptom  of  peritonitis,  and  that  it 
does  not  exist  in  uncomplicated  cellulitis.  The  swellings  of  cellulitis 
are  certainly  sometimes  remarkably  free  from  tenderness,  and  I  have 
often  seen  masses  of  exudation  in  the  iliac  fossae  which  could  bear  even 
rough  handling.  On  the  other  hand,  although  this  is  certainly  more 
often  met  with  in  non-puerperal  cases,  the  tenderness  over  the  abdomen 
is  sometimes  excessive,  the  patient  shrinking  from  the  slightest  touch. 
The  pulse  is  raised,  generally  from  100  to  120,  and  the  thermometer 
shows  the  presence  of  pyrexia.  During  the  entire  course  of  the  disease 
both  these  symptoms  continue.  The  temperature  is  often  very  high,  but 
more  frequently  it  varies  from  100°  to  104°,  and  it  generally  shows 
more  or  less  marked  remissions.  In  some  cases  the  temperature  is  said 
not  to  be  elevated  at  all,  or  even  to  be  subnormal,  but  this  is  certainly 
quite  exceptional.  Other  signs  of  local  and  general  irritation  often 
exist.  Among  them — and  most  distinctly  in  cases  of  peritonitis — are 
nausea  and  vomiting  and  an  anxious,  pinched  expression  of  the  counte- 
nance, while  the  local  mischief  often  causes  distressing  dysuria  and 
tenesmus.  The  latter  is  especially  apt  to  occur  when  there  is  exudation 
between  the  rectum  and  vagina,  which  presses  on  the  bowel.  The  pas- 
sage of  feces,  unless  in  a  very  liquid  form,  may  then  cause  intolerable 
suifering. 

The  fSijmptoms  often  Insidious  in  their  Onset. — Such  symptoms  may 
show  themselves  within  a  few  days  after  delivery,  and  then  they  can 
barely  fail  to  attract  attention.  On  the  other  hand,  they  may  not  com- 
mence for  some  weeks  after  labor,  and  then  they  are  often  insidious  in 
their  onset  and  apt  to  be  overlooked.  It  is  far  from  rare  to  meet  with 
cases  six  weeks  or  more  after  confinement  in  which  the  patient  complains 
of  little  beyond  a  feeling  of  malaise  and  discomfort,  and  in  M^hich,  on 
investigation,  a  considerable  amount  of  exudation  is  detected  which 
iiafl  ])revi(jusly  entirely  escaped  observation, 

Resulbi  of  Phi/.sical  Examination. — On  introducing  the  finger  into  the 
vagina  it  will  be  found  to  be  hot  and  swollen,  in  some  cases  distinctly 
fecleniatous,  and  on  rea(;liing  the  vaginal  cnl-de-.^ar  the  existence  of  exu- 
dation may  generally  b(!  made  out.  TIk;  ainoinit  of  this  varies  nnich. 
Sometimes,  (;s|)ecially  in  the  (!arly  stag(!  of  tlu;  disease,  tliei'c  is  little  more 
than  a  diffuse  s(;nse  of  thif^kness  and  induration  at  either  side  of,  or 
behind,  the  nt(,'rns.  More  generally,  (;areful  bi-manual  examination 
enables  us  t(;  detect  a  distinct  hardening  and  swelling,  ])()ssibly  a  tumor 


648  THE  PUERPERAL  STATE. 

of  considerable  size,  which  may  apparently  be  attached  to  the  sides  of 
the  uterus  and  rise  above  the  pelvic  brim,  or  may  extend  quite  to  the 
pelvic  walls.  The  examination  should  be  very  carefully  and  systemat- 
ically conducted  with  both  hands,  so  as  to  exjjlore  the  whole  contour  of 
the  uterus  before,  behind,  and  on  either  side,  as  well  as  the  iliac  fossse, 
otherwise  a  considerable  exudation  might  readily  escape  detection.  When 
the  exudation  is  at  all  great  more  or  less  fixity  of  the  uterus  is  sure  to 
exist,  and  is  a  very  characteristic  symptom.  The  womb,  instead  of  being 
freely  movable  by  the  examining  finger,  is  firmly  fixed  by  the  surround- 
ing exudation,  and  in  severe  forms  of  the  disease  is  quite  encased  in  it. 
More  or  less  displacement  of  the  organ  is  also  of  common  occurrence. 
If  the  swelling  be  limited  to  one  side  of  the  pelvis  or  to  Douglas's  space, 
the  uterus  is  displaced  in  the  opposite  direction,  so  that  it  is  no  longer 
in  its  usual  central  position. 

The  TiDO  Forms  cannot  Always  be  DisUnguished. — The  diiferential 
diagnosis  of  pelvic  cellulitis  and  pelvic  peritonitis  cannot  always  be 
made,  and  indeed  in  many  cases  it  is  impossible,  since  both  varieties  of 
disease  coexist.  The  elements  of  differentiation  geilerally  insisted  on 
are  the  greater  general  disturbance,  nausea,  etc.  in  pelvic  peritonitis, 
with  an  earlier  commencement  of  the  symptoms  after  labor.  The  swellings 
of  pelvic  peritonitis  are  also  more  tender,  with  less  clearly-defined  out- 
line than  those  of  cellulitis.  When  the  cellulitis  involves  the  iliac  fossa, 
the  diagnosis  is  of  course  easy,  and  then  a  continuous  retraction  of  the 
thigh  on  the  affected  side  (an  involuntary  position  assumed  with  the  view 
of  keeping  the  muscles  lining  the  iliac  fossa  at  rest)  is  often  observed. 
When  the  inflammation  is  chiefly  limited  to  the  cavity  of  the  pelvis,  the 
distinction  between  the  two  classes  of  cases  cannot  be  made  with  any 
degree  of  certainty. 

Terminations. — Both  forms  of  disease  may  end  either  in  resolution  or 
in  suppuration.  In  the  former  case,  after  the  acute  symptoms  have 
existed  for  a  variable  time — it  may  be  for  a  few  days  only,  it  may  be 
for  many  weeks — their  severity  abates,  the  swellings  become  less  tender 
and  commence  to  contract,  become  harder,  and  are  gradually  absorbed, 
until  at  last  the  fixity  of  the  uterus  disappears,  and  it  again  resumes  its 
central  position  in  the  pelvic  cavity.  This  process  is  often  very  gradual. 
It  is  by  no  means  rare  to  find  a  patient,  even  some  months  after  the 
attack,  when  all  acute  symptoms  have  long  disappeared,  who  is  even 
able  to  move  about  without  inconvenience,  in  Avhum  the  uterus  is  still 
immovably  fixed  in  a  mass  of  deposit  or  is  at  least  adherent  in  some 
part  of  its  contour.  More  or  less  permanent  adhesions  are  of  common 
occurrence,  and  give  rise  to  symptoms  of  considerable  obscurity,  which 
are  often  not  traced  to  their  proper  source. 

Symptoms  of  Suppuration. — When  the  inflammation  is  about  to  ter- 
minate in  suppuration,  the  pyrexial  symptoms  continue,  and  eventually 
well-marked  hectic  is  developed,  the  temperature  generally  showing  a 
distinct  exacerbation  at  night.  At  the  same  time,  rigors,  loss  of  appetite, 
a  peculiar  yellowish  discoloration  of  the  face,  and  other  signs  of  suppu- 
ration show  themselves.  The  relative  frequency  of  this  termination  is 
variously  estimated  by  authors.  Duncan  quotes  Simpson  as  calculating 
it  as  occurring  in  half  the  cases  of  pelvic  cellulitis,  but  states  his  o^^n 


PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS.  649 

belief  that  it  is  much  more  frequent.  West  observed  it  in  23  out  of  43 
cases  following  delivery  or  abortion,  and  McClintock  in  37  out  of  70. 
Schroeder  says  that  he  has  only  once  seen  suppuration  in  92  cases  of  dis- 
tinctly demonstrable  exudation — a  result  which  is  certainly  totally  opposed 
to  common  experience.  Barker  also  states  that  in  his  experience  suppu- 
ration in  either  pelvic  peritonitis  or  cellulitis  "  is  very  rare,  except  when 
they  are  associated  with  pyaemia  or  puerperal  fever."  It  is  certain  that 
suppuration  is  more  likely  to  occur  in  pelvic  cellulitis  than  in  pelvic 
peritonitis,  but  it  unquestionably  occurs,  in  this  country  at  least,  much 
more  frequently  than  the  statements  of  either  of  these  authors  would 
lead  us  to  suppose. 

Channels  through  ivhich  Pus  may  Escape. — The  pus  may  find  an  exit 
through  various  channels.  In  pelvic  cellulitis,  more  especially  when  the 
areolar  tissue  of  the  iliac  fossa  is  implicated,  the  most  common  site  of 
exit  is  through  the  abdominal  wall.  It  may,  however,  open  at  other 
positions,  and  the  pus  may  find  its  way  through  the  cellular  tissue  and 
point  at  the  side  of  the  anus  or  in  the  vagina,  or  it  may  take  even  a  more 
tortuous  course  and  reach  the  inner  surface  of  the  thigh.  Pelvic  ab- 
scesses not  uncommonly  open  into  the  rectum  or  bladder,  causing  very 
considerable  distress  from  tenesmus  or  dysuria.  According  to  Hervieux, 
it  is  chiefly  the  peritoneal  varieties  which  open  in  this  way.  Not  unfre- 
quently  more  than  one  opening  is  formed,  and  when  the  pus  has  bur- 
rowed for  any  distance  long  fistulous  tracts  result,  which  secrete  pus 
for  a  length  of  time  and  are  very  slow  to  heal.  Rupture  of  an  abscess 
into  the  peritoneal  cavity,  especially  of  a  peritonitic  abscess,  is  a  possible 
(but  fortunately  a  very  rare)  termination,  and  will  generally  prove  fatal 
by  producing  general  peritonitis.  In  one  case,  which  I  have  recorded  in 
the  fifteenth  volume  of  the  Obstetrical  Transactions,  suppuration  was 
followed  by  extensive  necrosis  of  the  pelvic  bones.  Two  similar  cases 
are  related  by  Trousseau  in  his  Clinical  Medicine,  but  I  have  not  been 
able  to  meet  with  any  other  examples  of  this  rare  complication,  wliich 
was  probably  rather  the  result  of  some  obscure  septicemic  condition 
than  of  extension  of  the  inflammation. 

Prognosis. — The  prognosis  is  favorable  as  regards  ultimate  recovery, 
but  there  is  great  risk  of  a  protracted  illness  which  may  seriously  impair 
the  health  of  the  patient,  especially  if  suppuration  result.  Hence  it  is 
necessary  to  be  guarded  in  an  expression  of  opinion  as  to  the  conse- 
quences of  the  disease.  Secondary  mischief  is  also  far  from  unlikely  to 
follow  from  the  physical  changes  produced  by  the  exudation,  such  as 
permanent  adhesions  or  malpositions  of  the  uterus  or  organic  alterations 
in  the  ovaries  or  Fallopian  tubes. 

Treatment. — In  the  treatment  of  both  forms  of  disease  the  important 
]w^ints  to  bear  in  mind  an;  the  relief  of  pain  and  the  necessity  of  abso- 
lute rest;  and  to  these  objects  all  our  measures  must  be  subordinate, 
since  it  is  (|uite  lio[)eless  to  attempt  to  cut  short  the  inflammation  by 
any  active  UKMlication. 

If  the  disease  be  recognized  at  a  very  early  stage,  the  local  abstraction 
of  blood,  by  the  appli(;ation  of  a  few  leeches  to  tlie  groin  or  to  the  hem- 
orrhoidal veins,  may  give  relief;  but  the  influence  of  this  remedy  has 
been  greatly  exaggerated,  nnd  wlien  the  disease  is  of  any  standing  it  is 


650  THE  PUERPERAL  STATE. 

quite  useless.  Leeches  to  the  uterus,  often  recommended,  are,  I  believe, 
likely  to  do  more  harm  than  good  (unless  in  very  skilful  hands),  from 
the  irritation  produced  by  passing  the  speculum.  Opiates  in  large  doses 
may  be  said  to  be  our  sheet-anchor  in  treatment  whenever  the  pain  is  at 
I  all  severe,  either  by  the  mouth,  in  the  form  of  morphia  suppositories,  or 
injected  subcutaneously.  In  the  not  uncommon  cases  in  which  pain 
comes  on  severely  in  paroxysms  the  opiates  should  be  administered  in 
.sufficient  quantity  to  lull  the  pain ;  and  it  is  a  good  plan  to  give  the 
nurse  a  supply  of  morjjliia  suppositories  (which  often  act  better  than  any 
other  form  of  administering  the  drug),  with  directions  to  use  them 
immediately  the  pain  threatens  to  come  on.  When  there  is  much 
pyrexia  large  doses  of  quinine  may  be  given  with  great  advantage  along 
with  the  opiates.  The  state  of  the  bowels  requires  careful  attention. 
The  opiates  are  apt  to  produce  constipation,  and  the  passage  of  hardened 
feces  causes  much  suffering.  Hence  it  is  desirable  to  keep  the  bowels 
freely  open.  Nothing  answers  this  purpose  so  well  as  small  doses  of 
castor  oil,  such  as  half  a  teaspoonful  given  every  morning.  Warmth 
and  moisture,  constantly  applied  to  the  lower  part  of  the  abdomen, 
either  in  the  form  of  large  poultices  of  linseed  meal,  or,  if  these  prove 
too  heavy,  of  spongio-piline  soaked  in  boiling  water,  give  great  relief. 
The  j)ouitices  may  be  advantageously  sprinkled  with  laudanum  or  bel- 
ladonna liniment.  I  say  nothing  of  the  use  of  mercurials,  iodide  of 
potassium,  and  other  so-called  absorbent  remedies,  since  I  believe  them 
to  be  quite  valueless  and  apt  to  divert  attention  from  more  useful  plans 
of  treatment. 

Iiivportance  of  Bed. — The  most  absolute  rest  in  the  recumbent  posi- 
tion is  essential,  and  it  should  be  persevered  in  for  some  time  after  the 
intensity  of  the  symptoms  is  lessened.  The  beneficial  effect  of  rest  in 
alleviating  pain  is  often  seen  in  neglected  cases  the  nature  of  which  has 
j  been  overlooked,  instant  relief  following  the  laying  up  of  the  patient. 

Counter-irritation. — When  the  acute  symptoms  have  lessened,  absorp- 
tion of  the  exudation  may  be  favored  and  considerable  relief  obtained 
from  counter-irritation,  which  should  be  gentle  and  long  continued. 
The  daily  use  of  tincture  of  iodine  until  the  skin  peels  perhaps  best 
meets  this  indication,  but  frequently-repeated  blisters  are  often  very  ser- 
viceable. This  I  believe  to  be  a  better  plan  than  keeping  up  an  open 
sore  with  savine  ointment  or  similar  irritating  applications. 

Opening  of  Pelvic  Abscesses. — When  suppuration  is  established  the 
question  of  opening  the  abscess  arises.  When  this  points  in  the  groin 
and  the  matter  is  sujaerficial,  a  free  incision  may  be  made ;  and  here,  as 
in  mammary  abscess,  the  antiseptic  treatment  is  likely  to  prove  very  ser- 
viceable. The  abscess  should,  however,  not  be  opened  too  soon,  and  it 
is  better  to  wait  until  the  pus  is  near  the  surface.  The  importance  of 
not  being  in  too  great  a  hurry  to  open  pelvic  abscesses  has  been  insisted 
on  by  West,  Duncan,  and  other  writers,  and  I  have  no  doubt  the  rule 
is  a  good  one.  It  is  more  especially  applicable  when  the  abscess  is 
pointing  in  the  vagina  or  rectum,  where  exploratory  incisions  are  apt 
to  be  dangerous,  and  when  the  presence  of  pus  should  be  positively 
ascertained  before  operating.  We  have  in  the  aspirator  a  most  useful 
instrument  in  the  treatment  of  such  cases,  which  enables  us  to  remove 


PELVIC  CELLULITIS  AND  PELVIC  PERITONITIS.  651 

tlie  greater  part  of  the  j)us  without  any  risk,  and  the  use  of  which  is  not 
attended  with  danger  even  if  employed  prematurely.  If  it  do  not  suffi- 
ciently evacuate  the  abscess,  a  free  opening  can  afterward  be  safely  made 
with  the  bistoury.  The  surgical  treatment  of  pelvic  abscess  is,  however, 
too  wide  a  subject  to  admit  of  being  satisfactorily  treated  here. 

Diet  and  Regimen. — The  diet  should  be  abundant,  but  simple  and 
nutritious.  In  the  early  stages  of  the  disease  milk,  beef-tea,  eggs,  and 
the  like  will  be  sufficient.  After  suppuration  a  large  quantity  of  ani- 
mal food  is  necessary,  and  a  sufficient  amount  of  stimulants.  The  drain 
on  the  system  is  then  often  very  great,  and  the  amount  of  nourishment 
patients  will  require  and  assimilate  when  a  copious  purulent  discharge  is 
going  on  is  often  quite  remarkable.  A  general  tonic  plan  of  medication 
is  also  indicated,  and  such  drugs  as  iron,  quinine,  and  cod-liver  oil  will 
prove  useful. 


/ 


INDEX. 


ABDOMEN,  adipose  enlargement  of,  157 
enlargement  of,   as   a   sign   of  preg- 
nancy, 149 
state  of,  after  delivery,  551 
Abdominal  pregnancy.     See  Extra-uterine 

Pregnancy. 
Abortion,  242 

causes  of,  244 

difficulty  in  procuring  artificial,  248 
liability  to  recurrence  of,  243 
production   of,  in  vomiting  of  preg- 
nancy, 201 
retention  of  secundines  in,  249,  253 
symptoms  of,  248 
treatment  of,  249 

value  of  opium  in  prevention  of,  249 
[250] 
Abscess  of  mammae.     See  Mammary  Ab- 
scess. 
Abscess,  pelvic.     See  Pelvic  Cellulitis. 
After-i3ains,  552 

treatment  of,  554 
Age,  influence  of,  in  labor,  340 
Albuminuria  in  pregnancy,  206 
relation  of,  to  eclampsia,  576 
relation  of,  to  puerperal  insanity,  586 
Allantois,  167 
Amnii,  liquor,  109 
Amnion,  formation  of,  106 
pathology  of,  236 
structure  of,  109 
Amputations  (intra-uterine),  240 
Anseraia  in  pregnancy,  206 
Anaesthesia  in  labor,  295 

in  forceps  operations,  478 
value  of,  in  difficult  cases  of  turning, 
470 
Anasarca  in  pregnancy,  209 
Anteversion  of  the  gravid  uterus,  217 
Antisei)tic  midwifery,  604 
Apoplexy  during  or  after  labor,  635 
Arbor  vitie,  59 
Area  germinativa,  105 
Area  pellucida,  105 
Areola,  80 

changes  of,  during  pregnancy,  146 
Arm,  presentation  of.     See  Shoulder  Pre- 
Henlalion. 
dorsal  displacement  of,  330 
Arterial  transfusion,  542 
Artificial  himian  milk,  571 
Artificial  respiration  in  cases  of  apparent 
still-birth,  558 


Ascites  ciS  a  cause  of  dystocia,  373 
Asphyxia  (idiopathic),  635 

of  new-born  children,  557 
Atropine,  hypodermic  injection  of,  in  ri- 
gidity of  cervix,  352 
Auscultatory  signs  of  pregnancy,  152 


BAGS  (Barnes's).     See  Dilators. 
Ballottement,  151 
Basilyst,  the,  508 
Bi-lobed  uterus,  gestation  in,  192 
Binder,  uses  of,  294 

[application  of,  290] 
Bladder,  distension  of,  as  a  cause  of  pro- 
tracted labor,  340 
exfoliation  of  lining  membrane  of,  213 
state  of,  after  delivery,  553 
Blastodermic  membrane,  99 

division  and  layers  of,  105 
Blood,  alteration  in,  after  delivery,  547 
changes  of,  during  pregnancy,  139 
Blood-diseases  transmitted  to  foetus,  237 
Blunt-hook  in  breech  presentation,  309 
Bowels,  action  of,  after  delivery,  556 
Breech  presentations.     See   Pelvic  Presen- 
tations. 
Broad  ligaments  of  uterus,  68 
Bronchitis  as  a  cause  of  protracted  labor, 

340 
Brow  presentations,  318 


C^SAEEAN  section,  330,  359,  398,  511, 
513 
[in  America,  525] 
[in  Great  Britain,  525] 
causes  of  mortality  after,  517 
causes  requiring  the  operation,  575 
description  of,  521 
history  of,  511 

[impi'oved  methods  of  performing,523  j 
[mortidity  in   cases  of  fibroid  tumor, 

357] 
[in  pelvic  exostosis,  388] 
post-mortem  operation,  516 
[process  of  Cohnstcin,  523] 

[of  Vnvnk,  522] 

[of  Kehrer,  524] 

[of  Siinger,  524] 
results  to  child  in,  574 
[results   in    fireat    Britain    and    the 

United  States  compared,  525] 

653 


654 


INDEX. 


Csesarean  section — 

statistics  of,  513 

[latest  American.  513] 

[in  American  dwarfs,  514] 

substitutes  for,  526 

sutures  in,  522 

[sutures  in  the  United  States,  522] 

[in  transverse  position  of  foetus,  330] 
Calculus  of  bladder  obstructing  labor,  359 
Caput  succedaneum,  279 
Carcinoma  in  jjregnancy,  223 

obstructing  labor,  353 
Cardiac  murmurs  in  pulmonary  obstruc- 
tion, 629 
Caries  of  teeth  in  pregnancy,  204 
[Carolina  twins,  birth  of,  370] 
Carunculse  myrtiformes,  52 
Catheter,  introduction  of,  51 
Caul,  264 

Cellulitis,  pelvic.     See  Pelvic  Cellulitis. 
Cephalotribe,  500 
Cephalotripsy.     See  Craniotomy. 
Cervix  uteri,  58 

alterations  of,  after  childbirth,  58 

cavity  of,  59 

dilatation  of,  in  labor,  259 

hypertrophic  elongation  of,  353 

impaction  of,  before  foetal  head,  286 

incision  of,  for  rigidity,  354 

lacerations  of,  439 

modification  of,  by  pregnancy,  136 

mucous  membrane  of,  63 

organic  causes  of  rigidity  of,  353 

rigidity  of,  as  a  cause  of  protracted 
labor,  351 

treatment  of  rigidity,  352 

villi  of,  64 
Charlotte,  Princess  of  Wales,  death  of,  348 
Child  (the  new-born).     See  Infant. 
Child,  risks  to,  in  forceps  operations,  486 
Childlairth,  mortality  of,  546 
Chloral  in  labor,  295 

in  rigidity  of  cervix,  352 
Chloroform  in  labor,  296 

[deaths  from,  297] 

in  difficult  cases  of  turning,  462 

in  rigidity  of  cervix,  352 
Chorea  in  pregnancy,  212 
Chorion,  110 

vesicular  degeneration  of,  229 
Circulation  of  foetus,  129 
Cleavage  of  yelk,  99 
Clitoris,  48 
Coccyx,  35 

ligaments  of,  36 

ossification  of,  36 

mobility  of,  36 
Cold  in  the  treatment  of  puerperal  hyper- 
pyrexia, 619 
Colostrum,  559 
Complex  jiresenfations,  330 
Conception,  signs  of,  143 
Constipation  in  pregnancy,  202 
Constriction  of  uterus,  tetanoid,  355 
Continued  fever  in  pregnancy,  221 


Convulsions  puerperal.     See  Eclampsia. 
Corps  reticule,  108 
Corpus  luteum,  84 

false,  85 
Cranioclast,  500 
Craniotomy,  497 

cases  requiring,  502 

comparative  merits  of,  and  cephalo- 
tripsy, 505 

description  of  cephalotrijjsy,  506 

extraction  of  head  by  craniotomy  for- 
ceps, 508 

method  of  perforating,  504 

perforators,  499 

perforation  of  after-coming  head,  505 

religious  objections  to,  498 
Craniotomy  forceps,  500 
Crotchets,  499 

Cyclical  theory  of  menstruation,  92 
Cystocele,  obstructing  labor,  359 


DEATH,  apparent,  of  new-born   child. 
See  Infant. 

sudden,  during  labor  and  the  puer- 
peral state,  635 

from  air  in  the  veins,  636 

functional  causes  of,  635 

organic  causes  of,  635 
Decapitation  of  foetus,  510 
Decidua,  100 

at  end  of  pregnancv  and  after  deliv- 
ery, 104 

cavity  between  d.  vera  and  reflexa, 
104 

divisions  of,  1 00 

fatty  degeneration  of,  as  the  cause  of 
labor,  256 

formation  of  d.  reflexa,  102 

structure  of,  101 
Delivery,  state  of  patient  after,  547 

contraction  of  uterus  after,  549 

management  of  patient  after,  553 

nervous  shock  after,  547 

prediction  of  date  of,  161 

signs  of  recent,  164 

state  of  pulse  after,  547 

weight  of  uterus  after,  550 
Diabetes,  143 
Diameters  of  foetal  skull,  127 

of  pelvis,  41 
Diarrhoea  in  pregnancy,  202 
[Diet,  milk,  in  nursing  mothers,  564] 
Diet  of  lying-in  women,  554 
Dilators  (caoutchouc)  in  the  induction  of 
jjremature  labor,  453 

in  rigidity  of  cervix,  353 
Diphtheria  in  the  puerperal  state,  600 
Diseases  of  pregnancy,  198 

albuminuria,  206 

anaemia  and  chlorosis,  206 

carcinoma,  223 

cardiac  diseases,  222 

chorea,  212 

constipation,  202 


INDEX. 


655 


Diseases  of  pregnancy — 

diarrhoea,  202 

disorders  of  the  nervous  system,  211 
respiratory  organs,  204 
teeth,  204 
urinary  system,  213 

displacements  of  tlie  gravid  uterus,  216 

epilepsy,  223 

eruptive  fevers,  221 

tibroid  tumors,  225 

haemorrhoids,  203 

icterus,  223 

leucorrhcea,  214 

ovarian  tumor,  224 

palpitation,  205 

paralysis,  211 

pneumonia,  221 

pruritus,  215 

ptj'alism,  204 

syncope,  205 

syphilis,  222 

varicose  veins,  215 

vomiting  (excessive),  198 
Dropsies  affecting  the  foetus,  239 
Ductus  arteriosus,  129 

venosus,  129 
Dystocia  from  foetus,  363 


ECLAMPSIA,  573 
cause  of  death  in,  576 

condition  of  patient  between  the  at- 
tacks, 575 

confusion  from    defective   nomencla- 
ture, 573 

exciting  causes  of,  578 

obstetric  management  in,  581 

pathology  of,  576 

premonitory  symptoms  of,  574 

relation  of,  to  labor,  575 

results  to  mother  and  child  in,  576 

symptoms  of,  574 

transfusion  in,  536 

Traiibe  and  Rosenstein's  theory  of,  577 

treatment  of,  579 

ursemic  theory  of,  576 

venesection  in,  579 

views  of  MacDonald,  578 
Ecraseur,  use  of,  as  a  substitute  for  cranio- 
tomy, 501 
Embolism.     See  Tlirombosis. 
Embryotomy,  509 
Emotion,  mental,  as  a  cause  of  protracted 

labor,  340 
Epiblast,  105 

Epilepsy,  in  pregnancy,  223 
Epileptic  convulsions,  574 
Ergot  of  rye,  342 

as  a  means  of  inducing  labor,  452 

objections  to  use  of,  ."43 

mode  of  administration,  342 

value  oi',  alter  delivery,  294 
Krgotin,  hypodermic  inje(!tion  of,  in  post- 
partum hemorrhage.  422 
Eruptive  fevers  in  pregnancy,  221 


Erysipelas  as  a  cause  of  puerperal  sep- 
ticaemia, 599 

Ether  in  labor,  297  [298] 

Evisceration,  511 

Exhaustion,  importance  of  distinguishing 
between  temporary  and  permanent 
in  labor,  342 

Expression,  uterine  (see  Pressure) ;  of  the 
placenta,  291 

Extra-uterine  pregnancy,  171 
abdominal  variety  of,  182 
causes  of,  173 

changes  of  the  foetus  in,  185 
classification  of,  172 
diagnosis  of  abdominal  variety,  186 
diagnosis  of  tubal  variety,  177 
[faradic  current  in,  180] 
gastrotomy  in,  182,  187 
[non-removal  of  placenta  in,  179] 
[lajaarotomy,  primary  and  secondary, 

relative  risks  of,  189] 
pseudo-labor  in,  184 
vaginal  section  in,  179 
[Mathieson's  case  of,  179] 
symptoms  of  rupture  in,  176 
treatment  after  rupture,  182 
[Lawson  Tait's  operations,  182] 
treatment  of  abdominal  variety,  186 
tubal  variety,  175 

treatment  of  tubal  variety,  178 


FACE  presentation,  310 
causes  of,  310 
diagnosis  of,  311 
difficulties  connected  with,  317 
erroneous  views  formerly  entertained 

of,  310 
mechanism  of  delivery  in,  312 
mento-posterior  positions  in,  314 
prognosis  in,  316 
treatment  of,  316 
Fallopian  tubes,  71 
False  corpus  luteum,  85 
False  pains,  character  and  treatment  of, 

282,  283 
Faradization  in  apparent  stillbirth,  558 
in  destroying  the  vitality  of  the  foetus 

in  abnormal  pregnancies,  180 
in  hemorrhage  after  delivery,  426 
in  labor,  344 
Fibroid  tumor,  in  pregnancy,  225 
obstructing  labor,  356  [357] 
Fillet,  496 

in  breecli  presentations,  309 
nature  of  the  instrument,  496 
objections  to  its  use,  497 
Flattened  pelvis,  378 
Foetal  head,  anatomy  of,  120 

induction   of    premature    labor,    for 
large  size  of,  450 
Foetal  heart,  soimds  of,  in  pregnancy,  153 
Foetus,  anatomy  and  piiysiology  of,  118 
[anenceplialous,  producing  eneuresis, 
214] 


656 


INDEX. 


Foetus- 
appearance  of  a  putrid,  241 

appearance  of,  at  various  stages  of  de- 
velopment, 118 

at  term,  119 

circulation  of,  129 

changes   in    circulation   of,   as  cause 
of  labor,  255 

changes  in  position  of,  during  preg- 
nancy, 123 

[cleansing  without  water,  559] 

death  of  241 

detection  of  position  in  utero  by  pal- 
pation, 124 

early  viability  of,  243 

excessive  development  of,  as  a  cause 
of  diflicult  labor,  374 

explanation  of  its  position  in  utero, 
125 

functions  of,  127 

nutrition  of,  127 

pathology  of,  237 

position  of,  in  utero,  123 

respiration  of,  128 

signs  and  diagnosis  of  death  of,  242 
Fontanelles,  120 
Foot,  diagnosis  of  301 
Foot  presentations.  See  Pelvic  Presentations. 
Foramen  ovale,  129 
Forceps,  472 

action  of,  476 

advantages  of  pelvic  curve  in,  473 

application  of,  to  after-coming  head 
in  breech  presentations,  307 

application  of,  within  the  cervix,  355 

[carried  over   abdomen  to   complete 
delivery  of  head,  494] 

[at  inferior  strait,  491] 

[at  superior  strait,  493] 

cases  in  which  a  straight  instrument 
should  be  iised,  473 

dangers  of,  347,  485 

dangers  of,  to  child,  486 

description  of,  472 

description  of  the  operation,  479 

difference  between  high  and  low  ope- 
rations, 478 

disadvantages  of  a  weak  instrument, 
476 

frequent  use  of,  in  modern   practice, 
346,  472 

high  operations,  484 
[in  America,  486] 

long,  474 

preliminary  considerations  before  us- 
ing, 478 

short,  472 

use  of  anaesthetics  in  forceps  delivery, 
479 

use  of,  in  deformed  pelvis,  395 

use   of,  in  difficult  occipito-posterior 
positions,  320 

use  of,  in  protracted  labor,  346 

[Bedford's,  489] 

£Davis's,  488] 


Forceps — 

[Elliot's,  490] 

[Plodge's,  488] 

[Meigs's  craniotomy,  509] 

[.Sawver's,  490] 

[Wallace's,  488] 

[White's,  490] 
Forceps  saw,  501 
Fossa  navicularis,  53 
Funis.     See  Umbilicdl  Cord. 
Funnel-shaped  pelvis,  378 


pALACTAGOGUES,  564 

'  7  Galactorrhoea,  565 

Galvanism  as  a  means  of  inducing  labor, 

452 
Gangrene  of  limbs  from  arterial  obstruc- 
tion, 634 
Gastrotomy,  after  rupture  of  uterus,  438 

in  extra-uterine  pregnancy,  182,  187 
Gastro-elytrotomy.        See      Laparo-etytro- 

tomy. 
[Gastro-hysterotoray,  possibilities  of,  528] 
Generative  organs,  in  the  female,  48 

division  according  to  function,  48 
Germinal  vesicle,  disaj^pearance  of,  after 

impregnation,  98 
Gestation.     See  Pregnancy. 
Glycosuria  in  pregnancy,  143 

in  lactation,  549 
Graafian  follicle,  75 

structure  of,  77 


H.EMATOCELE,  obstructing  labor,  360 
[Hand,  introduction  of  in  occipito-pos- 
terior positions,  322] 
Hand-feeding  of  infants,  569 

ass's  milk  in,  569 

artificial  human  milk  in,  570 

causes  of  mortality  in,  569 

cow's   milk  in,  and   its  preparation, 
570 

goat's  milk  in,  570 

method  of,  572 
Head  presentations,  268 

description   of    cranial   positions    in, 
268,  269 

division  of,  269 

frequency  of  first  position,  268 

exiilanation  of,  270 

mechanism  of  first  position,  272 

second  position,  276 

third  position,  276 

fourth  position,  278 

relative   frequency   of   various    posi- 
tions, 269 
Heart,  diseases  of,  in  pregnancy,  222 

hypertrophy  of,  in  jjregnancy,  141 
Hemorrhage,  accidental,  411 

causes  and  pathology  of,  412 

concealed  internal,  413 

diagnosis,  prognosis,  and  treatment  of 
concealed  internal,  413,  414 


INDEX. 


657 


Hemom-hage — 

prognosis  of,  414 

symptoms  and  diagnosis  of,  412 

treatment  of,  414 

after  delivery,  415 

causes  of,  416 

constitutional  predisposition  to,  419 

curative  treatment  of,  421 

from  laceration  of  maternal  structures, 
427 

nature's    mode    of   preventing,    266, 
415 

preventive  treatment  of,  420 

secondary  causes  of,  417 

secondary  treatment  of,  427 

symptoms  of,  420 

transfusion  of  blood  in,  428 
after  delivery  (secondary),  428 

distinction   between,  and   profuse  lo- 
cliial  discharge,  428 

local  causes  of,  429 

treatment  of,  430 
unavoidable.     See  Placenta  Prcevia. 
Hemorrhoids,  in  pregnancy,  203 
Hernia,  in  labor,  360 
Hour-glass  contraction  of  uterus,  417  [418] 

ante-partum,  255 
Hydatids  of  uterus,  229 
Hydramnios,  236 

Hydrocephalus  of  foetus,  as  a  cause  of  dif- 
ficult labor,  371 
Hydrorrhcea  gravidarum,  228 
Hymen,  52 
Hypoblast,  105 
Hysteria  during  labor,  574 


INDUCTION  of  premature  labor.     See 
Premature  Labor. 
Inertia  of  the  uterus,  frequent  child-bear- 
ing as  a  cause  of,  339 
Infant,  apparent  death  of,  557 

appearance  of,  in  cases  of   apparent 

death,  557 
clothing  of,  559 
evils  of  over-suckling,  560 
management  of,  561 
management  of,  when  food  disagrees, 

573 
treatment  of  apparent  death  of,  557 
various  kinds  of  food  of,  572 
washing  and  dressing  of,  558 
Infantile   mortality,    diminution    of,   as  a 
reason  for  more  impicnt  use  of  for- 
ceps, 347_ 
Inflammatory  diseases  affecting  the  fa-tus, 

239 
Injections,  uterine,  of  hot  water,  424 
Insanity  fjiuorjjcral),  582 
chissification  of,  583 
of  lactation,  588 
of  pregnancy,  583 
predisposing  (rauses  of,  583 
|(Ufcr|)eral  (proper),  585 
causes  of,  585 

42 


Insanity — 

form  of,  prognosis  of,  584 

post-mortem  signs  of,  588 

symptoms  of,  588 

transient  mania  during  delivery,  584 

treatment  of,  590 

treatment  during  convalescence,  592 

question  of  removal  to  an  asylum,  592 
Insomnia  in  pregnancy,  211 
Intermittent  fever  affecting  the  foetus,  288  , 
Intestines,    disorders    of,    as    influencing 

labor,  340 
Inversion  of  uterus.     See  Uterus. 
Irregular  uterine  contractions  after  labor, 
417 

as  a  cause  of  lingering  labor,  341 
Irritable  bladder  in  pregnancy,  213 
Ischium,  planes  of  the,  46 


TAUNDICE  in  pregnancy,  223 

KIESTEIN,  142  [143] 
Knee  presentation,  301 
Knots  of  the  umbilical  cord,  235 
Kyphotic  deformity  of  pelvis,  386 


LABIA  majora,  49 
Labia  minora,  50 
Labor,  255 

age,  influence  of,  on,  340 

ansesthesia  in,  295 

arrest  of,  164 

causes  of,  255 

causes  of  precipitate,  350 

causes  of  protracted,  337 

character  and  source  of  pain  in,  261 

character  of  false  pains,  263 

dilatation  of  cervix  in,  257 

duration  of,  266 

effect  of  uterine  contractions  in,  257 

evil  effects  of  protracted,  337 

induction  of.     See  Premalure  Labor. 

influence  of  stage  of,  in  protracted,  337 

management  of,  in  deformed   pelvis, 
394 

management  of  natural,  280 

management  of  third  stage  of,  289 

mechanism  of,  in   head  presentation, 
268 

[missed,  causes  of,  195] 

obstructed  by  faulty  condition   of  the 
soft  parts,  351 

period  of  day  at  which   labor   com- 
mences, 267 

phenomena  of,  255 

position  of  patient  during,  285 

[premature,  induction  of,  456] 

jireparatory  treatment,  280 

precipitate,  350 

prolonged  and  precipitate,  337 

rupture  of  membranes  in,  259 

stages  of,  262 


658 


INDEX. 


Labor — 

symptoms  of  protracted,  338 

treatment  of  protracted,  341 
Lactation,  defective  secretion  of  milk  in, 
564 

diet  of  nursing  women  during,  562 

diseases  of  the  eye  during,  566 

evil  results  of  prolonged,  560 

excessive  flow  of  milk  in,  565 

importance  of,  to  mother,  560 

imjjortance  of  wet-nursing  to  child, 
560,  561 

insanity  of,  588 

management  of,  561 

means  of  arresting  secretion  of  milk 
in,  563 

period  of  weaning  in,  563 
Laminpe  dorsales,  105 
Laparo-elytrotomy,  529 

[latest  statistics  of,  530] 
[Laparotomies,  American  puerperal,  438] 
Lead-poisoning,  affecting  the  iVetus,  288 

as  a  cause  of  abortion,  247 
Leucorrhcea,  in  pregnancy,  214 
Lever.     See  Veeiis. 
Liquor  amnii,  109 

uses  of,  110 

source  of,  109 

deficiency  of,  237 
Lithopredion,  185 

Liver,  acute  yellow  atrophy  of,  223 
Lochia,  551 

variation  in  amount  and  duration  of, 
552 

occasional  fetor  of,  552 
Lying-in  hospitals,  moi-tality  in,  594 
Lypothjemia,  146,  205 

MALARIAL  puerperal  fever,  615 
Malpresentations,    peculiar    form   of 
bag  of  membranes  in,  301 
Mammary  abscess,  566 

antiseptic  treatment  of,  567 
signs  and  symptoms  of,  566 
treatment  of,  566 
changes  during  pregnancy,  148 
their  diagnostic  value,  79 
glands,  146 

their  sympathetic  relations  with  the 
uterus,  80 
Mania,    puerperal.     See    Insanity,    Puer- 
peral. 
Measles,  affecting  the  foetus,  238 
,        in  pregnancy,  221 
Meconium,  131 
Membranes,  artificial  rupture  of,  284 

puncture  of,  as  a  means  of  inducing 
labor,  451 
Menstruation,  81 
cessation  of,  93 
during  pregnancy,  144 
changes  in  Graafian  follicle  after,  81 
period   of,  duration,   and  recurrence, 
87 


Menstruation — 

purpose  of,  92 

source  of  blood  in,  89 

theory  of,  90 

quantity  of  blood  lost  in,  88 

vicarious,  92 
[Menstrual  life,  duration  of,  94] 
Mesoblast,  105 
Milk,  artificial  human,  570 

ass's,  569 

cow's,  and  its  preparation,  570 

defective  secretion  of,  564 

excessive  secretion  of,  565 

goat's,  570 

means  of  arresting  the  secretion  of, 
563 

secretion  of,  after  delivery,  560 

ti'ansfusion  of,  539 
Milk-fever,  548 
Miscarriage.     See  Abortion. 
Missed  labor,  193 
Moles,  245 
Monstrosity  (double),  367 

classification  of,  367 

mechanism  of  delivery  in,  367 
Mons  veneris,  49 
Montgomery's  cups,  102 
Morning  sickness,  145 
Mortality  of  childbirth,  546 
Mucous  membrane  of  uterus.     See  Uterus. 
Miiller's  operation,  526 
Myxoma  fibrosum,  232 


NEKVOUS  shock  after  delivery,  547 
Nervous    system,  changes    in,  during 

pregnancy,  141 
disorders  of,  in  pregnancy,  211 
excitability  of,  in  puerperal  women, 
578  _ 
Neuralgia  in  pregnancy,  211 
Nipple,  80 
Nipples,  depressed,  564 

fissures  and  excoriations  of,  564 
Nursing.     See  Lactation. 
Nutrition  of  foetus,  127 
Nymphae.     See  Labia  minora. 


OBLIQUELY  contracted  pelvis,  386 
Obstetric  bag,  281 
Occipito-posterior  positions,  difficult  cases 
of,  319 
causes  of  face-to-pubes  delivery  in, 

319 
[version  by  the  vertex,  321] 
forceps  in,  320 
treatment  of,  319 
vectis  or  fillet  in,  320 
Omphalo-mesenteric  artery  and  vein,  107 
Opiates,  use  of,  after  delivery,  553 
[Opium  to  arrest  labor  in  threatened  abor- 
tion, 250] 
Os  innominatum,  33 
Osteomalacia,  as  a  cause  of  deformity,  376 


INDEX. 


659 


Osteophytes,  formation  of,  during    preg- 
nancy, 141 
Os    uteri,   constriction   of   internal,    as  a 
cause  of  dystocia,  355 
dilatation  of,  as  a  means  of  inducing 

labor,  453 
occlusion  of,  in  labor,  354 
Ovarian     pregnancy.       See    Extra-uterine 
Pregnancy. 
tumor  in  pregnancy,  224 
Ovariotomy  in  pregnancy,  224 
Ovary,  72 

functions  of,  81 
structure  of,  74 
vascular  arrangements  of,  78 
Ovule,  77 

changes  in,  after  imjaregnation,  98 
changes  in,  when   retained   in  utero 

after  its  death,  245 
formation  of,  75 
Ovum,  blighted,  retained  in  utero,  245 
Oxytocic  remedies,  342 


PAINS,  after-,  552 
false,  282 
irregular  and  spasmodic,  as  a  cause  of 

protracted  labor,  341 
labor,  261 
Palpitation  in  pregnancy,  205 
Pampiniform  plexus,  65 
Paralysis  in  pregnancy,  211 

from  embolism  of  the  cerebral  arte- 
ries, 634 
from  embolism  of  the  main  arteries 
of  the  limb,  634 
Parovarium,  69 
Parturient  canal,  axis  of,  45 
Pathology  of  decidua  and  ovum,  227 
Pelvic  cellulitis  and  peritonitis,  644 
etiology  of,  645 
importance  of,  distinguishing  the  two 

forms  of  disease,  644 
connection  with  septicEemia,  645 
opening  of  abscess  in,  650 
prognosis  of,  649 
relative  frequency  of  the  two  forms 

of  disease,  646 
results  of  physical  examination,  647 
seat    of    inflammation    in    cellulitis, 

646 
seat  of  inflammation   in   peritonitis, 

646 
suppuration  in,  648 
symptomatology,  647 
terminations  of,  648 
treatment  of,  649 
two  distinct  I'onris  of  disease,  644 
Pelvic  prescnlations,  299 

ap|)ii(;atii)n    of   forceps   to   the   after- 
coming  head  in,  307 
causes  of,  2!»9 
danger  to  children  in,  300 
diagnosis  of,  300 
frecpiency  of,  299 


Pelvic  presentations — 

management  of  impacted  breech  in, 
308 

mechanism  of,  302 

prognosis  in,  299 

treatment  of,  306 
Pelvimeters,  various  forms  of,  392 
Pelvis,  alterations  in,  articulations  of,  dur- 
ing pregnancy,  39 

anatomy  of,  33 

articulations  of,  36 

axes  of,  45 

Csesarean   section   in   deformities   of, 
398 

causes  of  deformity  of,  375 

comjaarative  estimate  of  turning  and 
forceps  in  deformity  of,  397 

craniotomy  in  deformity  of,  398 

diagnosis  of  deformity,  391 

deformities  of,  375 

development  of,  46 

difference  according  to  race,  47 

differences  in  the  two  sexes,  41 

division  into  true  and  false,  34 

equally  contracted  377 

equally  enlarged,  377 

flattened,  378 

forceps  in  deformity  of,  395 

induction  of  premature  labor  in  de- 
formity of,  398 

infantile,  46 

[justo-minor  in  a  large  woman,  377] 

kyphotic,  386 

ligaments  of,  37 

funnel-shaped,  378 

masculine,  378 

mechanism  of  delivery  in  deformed, 
390 

movements  of  the  articulations  of,  38 

obliquely- contracted,  385 

planes  of,  385 

Robert's,  387 

scoliotic,  379 

soft  parts  connected  with,  48 

tumors  of,  388 

turning  in  deformity  of,  396 

undeveloped,  377 
Perchloride  of  iron,  injections  of,  in  post- 
partum liemorrhage,  426 
Perforation  of  after-coming  head,  504 
Perforators,  498 
Perineum,  distension  of,  in  labor,  264,  286 

incision  of,  287 

laceration  of,  288 

relaxation  of,  287 

rigidity   of,  as  a  cause  of  protracted 
lal)or,  356 
Peritonitis,  j)elvic.     See  Pelvic  Cdlidilix. 
[puerperal,  venesection  in,  618] 

puerperal.     See  Septlemmia. 
Phlegmasia  dolens.    See  ThromboKiti,  Peri- 
pheral, VenmiK. 
Placenta,  adhcsicm  of,  after  delivery,  41  i) 

degeneration  of,  116 

detachment  of,  in  labor,  265 


660 


INDEX. 


Placenta — 

expression  of,  291 

fcetal  portion  of,  112 

form  of,  in  man  and  animals.  111 

formation  of,  from  chorion,  110 

functions  of,  110 

maternal  jjortion  of,  114 

minute  structure  of,  112 

pathology  of,  232 

sinus  system  of,  114 

sounds  produced  during  separation  of, 
156 

treatment  of  adherent,  423 

treatment   of,   in   extra-uterine   fcsta- 
tion,  188 
Placenta  membranacea,  232 
Placenta  pnevia,  400 

causes  of,  400 

causes  of  lieraorrhage  in,  403 

natural  termination  of  labor  in,  405 

patliological  changes  of  placenta  in, 
405 

prognosis  in,  406 

sources  of  hemorrhage  in,  403 

summary  of  rules  for   treatment   in, 
410 

symptoms  of,  403 

treatment  of,  406 

turning  in,  408 

[by  Hicks'  method,  411] 
Placente  succenturia;,  232 
Placentitis,  233 
Plugging  of  vagina,  252 
Plural  births,  166,  363 

arrangement  of  placentte  and  mem- 
branes in,  168 

causes  of,  167 

diagnosis  of,  169 

relative    frequency    of,    in    different 
countries,  166 

sex  of  children  in,  167 

treatment  of,  363 
Pneumonia  in  pregnancy,  221 

puerperal  embolic,  632 
"  Polar  globule,"  99 
[Polypus  obstructing  labor,  362] 
Porro's  operation,  525 
[Porro-Cicsarean  statistic;^,  the  latest,  526] 
Position  of  cranium  in  liead  presentation. 

See  Head  Presentdtions. 
Post-partum    hemorrhage.      See    Hemor- 
rhage. 
Pregnancy,  132 

abnoi'mal,  166 

affections  of  respiratory  organs,  204 

alteration  of  color  of  vaginal  mucous 
membrane,  as  a  sign  of,  152 

ballottement,  as  a  sign  of,  151 

changes  in  tlie  blood  during,  139 

changes  in  the  liver,  lymphatics,  and 
spleen  during,  141 

changes  in  the  urine  during,  142 

complicated  with  ovarian  tumor,  224 

deposits  of  pigmentarv  matter  during, 
148 


Pregnancy — 

diabetes  in,  210 

differential  diagnosis  of,  157 

dress  of  patient  in,  280 

duration  of,  160 

enlargement  of  abdomen  as  a  sign  of,' 
149 

extra-uterine.   See  Extra-uterine  Prey- 
nancy. 

foetal  movements  in,  149 

formation  of  osteophytes  during,  141 

hypertrojahy  of  the  lieai't  during,  141 

in  cases  of  double  uterus,  07 

in  the  absence  of  menstruation,  145 

intermittent  uterine  contractions,  as  a 
sign  of,  150 

ptyalism  in,  204 

prolapse  of  the  uterus  in,  216 

protraction,  163 

pruritus  in,  215 

quickening,  149 

sickness  of,  145 

signs  and  diagnosis  of,  144 

sounds  produced  by  the  foetal   move- 
ments in,  156 

spurious,  159 

sympathetic  disturbances  of  145 

[tension  of    abdomen    in,    producing 
dyspnoea  at  night,  how  treated,  205] 

uterine  fluctuation  in,  151 

vaginal  pulsation  in,  151 

vaginal  signs  of,  151 
Premature  labor,  242 

historv  of  the  operation  of  induction 
of,  449 

induction  of,  449  [456] 

induction  of,  in  deformed  pelvis,  398 

injection  of   carbonic  acid    gas  as   a 
means  of  inducing,  455 

insertion  of  flexible  bougie  as  a  means 
of  inducing,  455 

objects  of  the  operation  of  induction 
of,  449 

oxytocics  as  a  means  of  inducing,  452 

period   for    the   induction  of,   in    de- 
formed pelvis,  399 

precautions  as  regards  the  child  in  the 
induction  of,  456 

puncture    of   the    membranes    as    a 
means  of  inducing,  451 

separation  of   the    membranes  as    a 
means  of  inducing,  454 

vaginal  and    uterine    douclies    as    a 
means  of  inducing,  454 
Pressure  as  a  means  of  inducing  uterine 
contractions,  344 

mode  of  applying,  345 
Prolapse  of  umbilical  cord.     See    Umbil- 
ical Cord. 
Ptyalism  in  pregnancy,  204 
Puerperal  convulsions.     See  Eclampsia. 
Puerperal  fever.     See  Septicaemia. 
Puerperal  mania.     See  Insanity. 
Puerperal  state,  546 

after-treatment  in,  556 


INDEX. 


661 


Puerperal  state — 

diet  and  reg-imen  in,  554 
diminution  of  uterus  in,  549 
importance  of  prolonged  rest  in,  556 
pulse  in,  547 

secretions  and  excretions  in,  548 
tempei-ature  in,  548 

Pulmonary  arteries,  anatomical  arrange- 
ment of,  as  favoring  thrombosis, 
624 


QUICKENING,  149 
Quinine  as  an  oxytocic,  343 


RACE,    as   influencing   the   size  of  the 
foetal  skull,  122 
Recto-vaginal  fistula,  439 
Respiration  of  foetus,  128 
Retroversion  of  the  gravid  uterus,  217 
Rickets  as  a  cause  of  pelvic  deformity,  376 
Rosenmiiller,  organ  of.     See  Parovarium, 
Round  ligaments  of  the  uterus,  70 
Rules  for  monthly  nurses,  556 
Rupture  of  uterus.     See  Uterus, 


SACRUM,  anatomy  of,  35 
mechanical  relations,  35 
Salivation  in  pregnancy,  204 
Scarlet  fever  affecting  the  foetus,  238 
in  pregnancy,  221 
in  the  puerperal  state,  600 
Scoliotic  deformity  of  pelvis,  379 
Scvbalse  in  the  rectum  obstructing  labor, 

'   _    360  ■ 

Septicaemia  (puerperal),  593 
bacteria  in,  605 
channels  of  diffusion  in,  605 
through  which  septic  matter  may  be 

absorbed,  597 
cold  in  ti'eatment  of,  619 
conduct  of  practitioner  in   regard  to, 

604 
contagion   from   other  puerperal  pa- 
tients as  a  cause  of,  602 
description  of,  609 
division  into  auto-genetic  and  hetero- 

genetic  forms,  598 
epidemics  of,  595 
history  of,  593 
importance  of  antiseptic  precautions 

in,  604 
influence   of    cadaveric    j)oison    as   a 

cause  of,  598 
influence  of  zymotic  disease  in    caus- 
ing, 600 
its  connection  with    pelvic   cclluiitiH 

and  f)eritonitis,  645 
local  changes  in,  605 
malarial,  6)5 
mode    in  wliich    tiie    jioisoii    may  be 

conveyed  to  patieiils  in,  603 
mortality  in  lying-in  liosjiitals,  594 


Septicaemia  (puerperal) — 

nature  of  septic  poison,  605 

pathological  phenomena  in,  607 

prevention  of,  604 

pygemic  forms  of,  614 

sewer  gas  as  a  source  of  infection,  601 

sources  of  auto-infection  in,  598 

of  hetero-infection,  598 

symptoms  of  the  intense  forms,  611 

theory  of  an  essential  zymotic  fever, 
595 

of  identity  with  surgical  septicaemia, 
596 

of  local  origin,  595 

transfusion  of  blood  in,  536 

treatment  of,  615 

venesection  in,  618 

Warburg's  tincture  in  the  treatment 
of,  619 
Sex,  discovery  of,  of  foetus  during  preg- 
nancy, 153 

of  foetus  as  influencing  the  size  of  the 
skull,  122 
Shoulder  presentations,  322 

diagnosis  of,  325 

division  of,  323 

mechanism  of,  327 

prognosis  and  frequency  of,  325 

spontaneous  version  in,  327 

spontaneous  evolution  in,  328 

treatment  of,  329 
Siamese  twins,  how  born,  368 
Sickness  of  pregnancy,  145 
Smallpox  affecting  the  foetus,  237 

in  pregnancy,  221 
Smith's,  Tyler,  theory  of  labor,  257 
Spondylolisthesis,  381  [382] 
Spondylolizema,  382 
Spontaneous  evolution,  328 

version,  327 
Spurious  pregnancy,  159 

diagnosis  of,  160 

symptoms  of,  159 
[Stethoscope,  Cammann's,  155] 
Stillbirth,  apparent,  557 
Symphyseotomy,  527 

[in  Italy,  revival  of,  529] 
Syncope  during  or  after  labor,  636 

in  pregnancy,  205 

[postural  treatment  of,  426] 
Syphilis  affecting  the  foetus,  238 

as  a  cause  of  abortion,  247 

in  pregnancy,  222 
Sugar,  in  urine  of  pregnancy,  143 
Sui)er-fecundation  and  super-foetation,  169 
Sutures  of  foetal  head,  120 


U<:MPERATURE  after  delivery,  548 
Tlirombosis  (periplicrnl  venous),  ()37 
cbiingcs  in  tliroinbi  in,  6-1 1 
condition  of  tlic  adcctcd  linil),  (538 
(iciacliincniof  cinl)oli  in,  641 
iiislory  ;uid  piilliology  of,  (;39 
progress  of  the  disease,  638 


662 


INDEX. 


Thrombosis  (periplieral  venous) — 

symptoms  of,  637 

treatment  of,  641 

(puerperal),  621 

arterial  thrombosis  and  embolism,  633 

cardiac  nuii'mur  in  pulmonary,  629 

cases  illustrating  recovery  from  pul- 
monary, 627-629 

causes  of  death  in  pulmonary,  630 

clinical  facts  in  favor  of  pulmonary, 
625 

conditions  which  favor  thrombosis  in 
the  puerperal  state,  623 

distinction  between   thrombosis    and 
embolism,  624 

phlegmasia  dolens  a  consequence  of, 
622 

post-mortem  appearance  of  clots   in 
pulmonary,  630 

pulmonary,  as  a  cause  of  pleuro-pneu- 
monia,  632 

question  of  primary  thrombosis  in  the 
pulmonary  arteries,  624 

question  of  recovery  from  pulmonary, 
626 

symptoms  of  arterial,  633 

of  pulmonary  obstruciion  in,  626 

treatment  of  arterial,  634 

of  pulmonary,  631 
Thrombosis  of  uterine  vessels,  416 
Thrombus.     See  Hcematocele. 
Toothache  in  pregnancy,  204 
Transfusion  of  blood,  534 

addition  of  chemical  reagents  to  pre- 
vent coagulation  of  fibrin,  538 

cases  suitable  for  the  operation,  540 

dangers  of  the  operation,  539 

defibrination  of  blood  in,  543 

difficulties  of  the  operation,  536 

effects  of  successful  transfusion,  545 

history  of  the  operation,  535 

immediate  transfusion,  537 

method     of     injecting     defibrinated 
blood,  544 

method    of    performing     immediate 
transfusion,  541 

method     of    preparing     defibrinated 
blood,  544 

nature   and   object  of  the  operation, 
536 

Schiifer's   directions    for    immediate, 
541 

secondary  effects  of,  545 

statistical  results  of,  539 
Tropics,    influence    of   residence    in,    on 

labor,  339 
Trunk,  presentation  of.  See  Shoulder  Pres- 
entations. 
Tumors,  diagnosis  of  uterine  and  ovarian, 
158 

foetal,  239 

obstructing  labor,  373 

(maternal)  obstructing  delivery,  358 
Tunica  albuginea,  74 
Turning,  457 


Turning — 

after  perforation,  505 

anassthesia  in,  462 

[bi-manual,    of    Hicks,   in    placenta 
prsevia,  411] 

by  combined  method,  462 

by  external  manipulation  only,  459 

cases  suitable  for  the  operation,  459 

operating  by  combined  method,  458 

cephalic,  457 

choice  of  hand  to  be  used,  462 

history  of  the  operation,  457 

in  abdomino-anterior  positions,  469 

in  deformed  pelvis,  396 

in  placenta  prtevia,  408,  468 

method  of  cephalic,  460 

of  performing  by  external  manipula- 
tion, 459 

of  podalic,  466 

object   and   nature  of  the  operation, 
458 

period  when  the  operation  should  be 
performed,  462 

podalic,  461,  465 

position  of  patient  in,  461 

statistics  and  dangers  of,  458 

value  of  anaesthetics  in  difficult  cases 
of,  470      ' 
Twins.     See  Plural  Births. 
Twins  [Carolina,  how  born,  370] 

[Carolina,  manner  of  birth  of,  370] 

conjoined,  367 

[Hungarian,    manner    of    birth     of, 
370] 

locked,  364 

[Siamese,  manner  of  birth  of,  368] 


UMBILICAL  cord,  117 
knots  of,  117,  235 
ligature  of,  289 
pathology  of,  235 
prolapse  of,  332 
cause  of,  333 
prolapse  of,  diagnosis  of,  333 
frequency  of,  332 
postural  treatment  of,  334 
prognosis  of,  333 
reposition  of,  335 
treatment  by  laceration,  289 
Umbilical  souffle,  155 

vesicle,  107 
Urachus,  108 

Uraemia,   in   connection   with    eclampsia, 
576 
in  connection  with  puerperal  insanity, 
586 
Urethra,  51 
Urine,  changes  in,  during  pregnancy,  142 

retention  of,  after  delivery,  553 
Uterine   fluctuation,   as    a  sign   of  preg- 
nancy, 151 
souflie,  155 
Utero-sacral  ligaments,  70 
Uterus,  56 


INDEX. 


663 


Uterus — 

analogy  of  interior  of,  after  delivery, 
and  stump  of  an  amputated  limb, 
105 
anomalies  of,  67 
ante-partum    hour-glass    contraction, 

355 
arrangement  of  muscular  fibres  of,  61 
axis  of,  during  pregnancy,  lo5 
changes  in  ce'rvix  during  pregnancy, 

135,  136 
changes  in  form  and  dimensions  of, 

during  pregnancy,  133 
changesin  mucous  membranes  of,  af- 
ter delivery,  550 
changes  in  mucous  membranes  of,  af- 
ter impregnation,  100 
changes   in  "tissues   of,  during   preg- 
nancy, 138 
changes  in  the  vessels  of,  after  deliv- 
ery, 550 
congestive  hypertrophy  of,  158 
contractions  of,  in  labor,  259 
dimensions  of,  58 
diminution  in  size  of,  after  delivery, 

549 
distension  of,  as  a  cause  of  labor,  256 
distension    of,    by    retained    menses, 

158 
fattv  transformation  of,  after  delivery, 

550 
hour-glass  contraction,  418 
intermittent  contractions    of,    during 

pregnancy,  150 
internal  surface  of,  59 
inversion  of,  442 
[inverted,  spontaneous   reposition  of, 

447] 
[painful  intermittent  contractions  of 

threatening  abortion,  150] 
[partitioned,  68] 

differential  diagnosis  of,  444 
production  of,  444 
results  of  physical    examination    in, 

443 
[rupture    of,   rational    treatment   of, 

441] 
symptoms  of,  443 
treatment  of,  446 
ligaments  of,  68 
lymphatics  of,  65 

malposition    of,  as   a   cause  of    pro- 
tracted hil)or,  341 
mode  of  action  in  labor,  259 
mucous  membrane  of,  61 
muscular  fibres  of,  61 
nerves  of,  67 
regional  divisions  of,  58 
relations  of,  56 
retroversion  of  gravid,  217 


Uterus — 

rupture  of,  431 

alterations  of  tissues  in,  433 

causes  of,  432 

comparative  result  of  various  methods 

of  treatment  in,  438 
prognosis  of,  436 
seat  of  laceration  in,  432 
symptoms  of,  435 
treatment  of,  437 
gastrotomy  in,  438 

size   of,    at  various  periods  of   preg- 
nancy, 134 
state  of,  in  protracted  labor,  339 
structures  composing,  60 
utricular  glands  of,  62 
vessels  of,  65 
weight  of,  after  delivery,  550 


VAGINA,  54 
bands  and   cicatrices   of,   obstructing 
delivery,  353 

contraction  of,  after  delivery,  551 

lacerations  of,  439 

orifice  of,  52 

structure  of,  54 
Varicose  veins  in  pregnancy,  215 
Vectis,  495 

action  of,  496 

cases  in  which  it  is  applicable,  496 
Veins,  entrance  of  air  into,  as  a  cause  of 

sudden  death  after  delivery,  636 
Venesection  for  rigidity  of  cervix,  352 
Version.     See  Turning. 
Vesico-uterine  ligaments,  71 
Vesico-vaginal  fistula,  439 
Vestibule,  51 

Vicarious  menstruation,  92 
Vomiting  in  pregnancy,  198 
Vulva,  48 

condition  of,  after  delivery,  551 

oedema  of,  obstructing  labor,  360 

vascular  supply  (ff,  53 
Vulvo-vaginal  glands,  52 


WARBURG'S  tincture,  619 
Weaning.     See  Lactation. 
Wet-nurse,  selection  of,  561 
Wolffian  bodies,  66,  118 
[Womanhood,  precocious  pliysical,  86] 
[Woman,  puerperal,  treatment  of,  618] 
Wounds  of  the  foatus,  240 


ZONA  pellucida,  77 
Zymotic   disease,   afTecting   the   foetus, 
238 
as  a  cause  of  septiciemia,  600 


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a  work  to  be  useful,  not  only  to  students,  but  to  j  faithfully  and  ably  executed. — Charleston  Medical 
practitioners  as  well.    It  reflects  credit  upon  the  |  Journal,  April,  1875. 


NEILL,  JOHN,  M.  D.,   and  SMITH,  F,  G.,  M.  D,, 

Late  Surf)eon  to  tlie  Penna.  Hospital.  Prof,  of  the  Institutes  of  Med.  in  the  Univ.  of  Penna. 

An  Analytical  Compendium  of  the  Various  Branches  of  Medical 
Science,  for  tlie  use  and  examination  of  Students.  A  new  edition,  revised  and  improved. 
In  one  large  royal  12rao.  volume  of  974  pages,  with  374  woodcuts.    Cloth,  |4 ;  leather,  $4.75. 


LUDLOW,  J.L,,M,D., 

C'lnsultinr/  Physician  to  the  Philadelphia  Hospital,  etc. 
A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  OlintetricH,  Materia  Medica,  CJIieniistry,  IMiiirmacy  and  Thera|)eutics.    To  which 
is  added  a  Medical  Formulary.     3d  edition,  tliorouglily  revised,  and  greatly  enlarged.     In 
one  12rao.  volume  of  816  pages,  with  370  illustrations.     Cloth,  $3.25;  leather,  $3.75. 

The  arrangement  of  this  volume  in  the  form  of  (jueHtion  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  tliose  preparing  for  graduation. 


4  Lea  Brothers  &  Co.'s  Publications — Dictionaries. 

DUJS^GLISOJ^,  ROBLET,  M,  D., 

Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON ;  A  Dictionary  of  Medical  Science :  Containing 
a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulpe  for  Officinal, 
Empirical  and  Dietetic  Preparations,  with  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Kichakd  J.  Dctnglison,  M.  D.  In  one  very  large  and 
handsome  royal  octavo  volume  of  1139  pages.  Cloth,  $6.50 ;  leather,  raised  bands,  $7.50 ; 
very  handsome  half  Kussia,  raised  bands,  $8. 

The  object  of  the  author,  from  the  outset,  has  not  been  to  make  the  work  a  mere  lexi- 
con or  dictionary  of  terms,  but  to  afford  under  each  word  a  condensed  view  of  its  various 
medical  relations,  and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of 
medical  science.  Starting  witli  this  view,  the  immense  demand  which  has  existed  for  the 
work  has  enabled  him,  in  repeated  revisions,  to  augment  its  completeness  and  usefulness, 
until  at  length  it  has  attained  the  position  of  a  recognized  and  standard  authority  wherever 
the  language  is  sjDoken.  Special  pains  have  been  taken  in  the  preparation  of  the  present 
edition  to  maintain  this  enviable  reputation.  The  additions  to  the  vocabulary  are  more 
numerous  than  in  any  previous  revision,  and  particular  attention  has  been  bestowed  on  the 
accentuation,  which  will  be  found  marked  on  every  word.  The  typographical  arrangement 
has  been  greatly  improved,  rendering  reference  much  more  easy,  and  every  care  has  been 
taken  with  the  mechanical  execution.  The  volume  now  contains  the  matter  of  at  least 
four  ordinary  octavos. 


About  the  first  book  purchased  by  the  medical 
student  is  the  Medical  Dictionary.  The  lexicon 
explanatory  of  technical  terms  is  simply  a  sine  qua 
non.  In  a  science  so  extensive  and  with  such  col- 
laterals as  medicine,  it  is  as  much  a  necessity 


passed  away,  probably  all  of  us  feared  lest  the  book 
should  not  maintain  its  place  in  the  advancing 
science  whose  terms  it  defines.  Fortunately,  Dr. 
Richard  J.  Dunglison,  having  assisted  his  father  in 
the  revision  of  several  editions  of  the  work,  and 


to  the  practising  physician.  To  meet  the  veants  of  I  having  been,  therefore,  trained  in  the  methods 
students  and  most  physicians  the  dictionary  must  I  and  imbued  with  the  spirit  of  the  book,  has  been 
be  condensed  while  comprehensive,  and  practical  I  able  to  edit  it  as  a  work  of  the  kind  should  be 
while  perspicacious.    It  was  because  Dunglison's  I  edited — to  carry  it  on  steadily,  without  jar  or  inter- 


met  these  indications  that  it  became  at  once  the 
dictionary  of  general  use  wherever  medicine  was 
studied  in  the  English  language.  In  no  former 
revision  have  the  alterations  and  additions  been 
so  great.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps; 
an  arrangement  which  greatly  facilitates  reference. 
— Cincinnati  Lancet  and  Clinic,  Jan.  10,  1874. 

A  book  of  which  every  American  ought  to  be 
proud.     When   the  learned  author  of   the  work 


ruption;  along  the  grooves  of  thought  it  has  trav- 
elled during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr.  Dunglison  has  assumed  and 
carried  through,  it  is  only  necessary  to  state  that 
more  than  six  thousand  new  subjects  have  been 
added  in  the  present  edition. — Philadelphia  Medical 
Times,  Jan.  3, 1874. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent  of 
references. — London  Medical  Gazette. 


SOBLYW,  BICJBTABJD  D.,  M.  D. 

A  Dictionary  of  the  Terms  IJsed  in  Medicine  and  the  Collateral 
Sciences.  Revised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  In  one  large  royal  12mo.  volume  of  520 
double-columned  pages.     Cloth,  $1.50 ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 
Medical  and  Surgical  Journal. 

STVJDBNTS'  SBBIES  OF  MANUALS, 

A  Series  of  Fifteen  Manuals,  for  the  use  of  »Students  and  Practitioners  of  Medicine 
and  Surgery,  written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size 
12mo.  volumes  of  300-540  pages,  richly  illustrated  and  at  a  low  price.  The  following  vol- 
umes are  now  ready:  Bell's  Comparative  Physiology  and  Anatomy,  Gould's  Surgical 
Diagnosis,  Robertson's  Physiological  Physics,  Brtjce's  Materia  Medica  and  Therapeutics, 
Power's  Human  Physiology,  Clarke  and  Lockwood's  Dissectors'  Manual,  Ralfe's 
Clinical  Chemistry,  Treves'  Surgical  Applied  Anatomy,  Pepper's  Surgical  Pathology,  and 
Klein's  Elements  of  Histology.  The  following  are  in  press :  Bellamy's  Operative  Surgery, 
Pepper's  Forensic  Medicine,  and  Curnow's  Medical  Applied  Anatomy.  For  separate 
notices  see  index  on  last  page. 

SEBIES  OF  CLINICAL  MANUALS. 

In  arranging  for  this  Series  it  has  been  the  design  of  the  publishers  to  provide  the 
profession  with  a  collection  of  authoritative  monograplis  on  important  clinical  subjects 
in  a  cheap  and  portable  form.  The  voliunes  will  contain  about  550  pages  and  will  be 
freely  illustrated  by  chromo-lithographs  and  woodcuts.  The  following  volumes  are 
now  ready:  Treves'  Manual  of  Surgery,  by  various  writers,  in  three  volumes;  Owen  on 
Surgical  Diseases  of  Children,  Morris  on  Surgical  Diseases  of  the  Kidney,  Pick  on  Fract- 
ures and  Dislocations,  Butlin  on  the  Tongue,  Treves  on  Intestinal  Obstruction,  and  Savage 
on  Insanity  and  Allied  Neuroses.  The  following  are  in  active  pi-eparation:  Hutchinson 
on  Syphilis,  Bryant  on  the  Breast,  Broadbent  on  the  Pulse,  Lucas  on  Diseases  of  the 
Urethra,  Marsh  on  Diseases  of  the  Joints,  and  Ball  on  the  Rectum  and  Anus.  For 
separate  notices  see  index  on  last  page. 


Lea  Brothers  &  Co.'s  Publications — Anatomy.  5 

GRAY,  JECJSJVUT,  F,  M.  S., 

Lecturer  oin  Anatomy  at  St.  George's  Hospital,  London. 

Anatomy,  Descriptive  and  Surgical.  The  Drawings  by  H.  V.  Cahteb,  M.  D., 
and  Dr.  Westmacott.  The  dissections  jointly  by  the  Author  and  Dr.  Carter.  With 
an  Introduction  on  General  Anatomy  and  Development  by  T.  Holmes,  M.  A.,  Surgeon  to 
St.  George's  Hospital.  Edited  by  T.  Pickering  Pick,  F.  E.  C.  S.,  Surgeon  to  and  Lecturer 
on  Anatomy  at  St.  George's  Hospital,  London,  Examiner  in  Anatomy,  Eoyal  College  of 
Surgeons  of  England.  A  new  American  from  the  tenth  enlarged  and  improved  London 
edition.  To  which  is  added  the  second  American  from  the  latest  English  edition  of 
Landmarks,  Medical  and  Surgical,  by  Luther  Holden,  F.  K.  C.  S.,  author  of 
"Human  Osteology,"  "A  Manual  of  Dissections,"  etc.  In  one  imperial  octavo  volume 
of  1023  pages,  with  564  large  and  elaborate  engravings  on  wood.  Cloth,  $6.00 ;  leather, 
$7.00  ;  very  handsome  half  Russia,  raised  bands,  $7.50. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  They  thus  form  a  complete  and 
splendid  series,  which  will  greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy, 
and  will  also  serve  to  refresh  the  memory  of  those  who  may  find  in  the  exigencies  of 
practice  the  necessity  of  recalling  the  details  of  the  dissecting-room.  Combining,  as  it 
does,  a  complete  Atlas  of  Anatomy  with  a  thorough  treatise  on  systematic,  descriptive 
and  applied  Anatomy,  the  work  will  be  found  of  great  service  to  all  physicians  Avho  receive 
students  in  their  offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the 
groundwork  of  a  thorough  medical  education. 

Landmarks,  Medical  and  Surgical,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by 
type  and  illustration  in  anatomical  study. 

There  is  probably  no  work  used  so  universally 
by  physicians  and  medical  students  as  this  one. 
It  is  deserving  of  the  confidence  that  they  repose 
in  it.  If  the  present  edition  is  compared  with  that 
issued  two  years  ago,  one  will  readily  see  how 
much  it  has  been  improved  in  that  time.  Many 
pages  have  been  added  to  the  text,  especially  in 
those  parts  that  treat  of  histology,  and  many  new 
cuts  have  been  introduced  and  old  ones  modified. 

■Journal  of  the  American  Medical  Association,  Sept. 


This  well-known  work  comes  to  us  as  the  latest 
American  from  the  tenth  English  edition.  As  its 
title  indicates,  it  has  passed  through  many  hands 
and  has  received  many  additions  and  revisions. 
The  work  is  not  susceptible  of  more  improvement. 
Taking  it  all  in  all,  its  size,  manner  of  make-up, 
its  character  and  illustrations,  its  general  accur- 
acy of  description,  its  practical  aim,  and  its  per- 
spicuity of  style,  it  is  the  Anatomy  best  adapted  to 
the  wants  of  the  student  and  practitioner. — Medical 
Record,  Sept.  15, 1883.  |  1, 188.3. 

Also  for  sale  separate — 
HOLiyBJS,  LTJTHBM,  F,  B.  C.  S., 

Surgeon  to  St.  Barthokmiew's  and  the  Foundling  Hospitals,  London. 

Landmarks,  Medical  and  Surgical.  Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Pennsylvania  Academy  of  the  Fine  Arts,  formerly  Lecturer  on  Anatomy  in  the  Phila- 
delphia School  of  Anatomy.     In  one  handsome  12mo.  volume  of  148  pages.     Cloth,  $1.00. 

This  little  book  is  all  that  can  be  desired  within  I  cians  and  surgeons  is  much  to  be  encouraged.    It 
its  scope,  and  its  contents  will  be  found  simply  in-  |  inevitably  leads  to  a  progressive  education  of  both 

the  eye  and  the  touch,  Vjy  which  the  recognition  of 
disease  or  the  localization  of  injuries  is  vastly  as- 
sisted. One  thorouglily  familiar  with  the  facts  here 
tauglit  is  capable  of  a  degree  of  accuracy  and  a 
confidence  of  certainty  which  is  otherwise  unat- 
tainable. We  cordially  recommend  the  Landmarks 
to  the  attention  of  every  physician  who  has  not 
yet  provided  himself  with  a  copy  of  this  useful, 
practical  guide  to  the  correct  placing  of  all  the 
anatomical  parts  and  organs. — Canada  Medical  and 
Surgical  Journal,  Dec.  1881. 


valuable  tf)  the  young  surgeon  or  physician,  since 
they  bring  before  him  such  data  as  he  require.s  at 
every  examination  of  a  patient.  It  is  written  in 
language  .10  clear  and  concise  that  one  ought 
almo.at  to  learn  it  by  heart.  Itteaches  diagnosis  hy 
external  examination,  ocular  and  palpable,  of  the 
bodv,  with  such  anatomical  and  physiological  facts 
as  flirectly  bear  on  the  subject.  It  is  eminently 
the  student's  and  young  practitioner's  book. — J'hp- 
sician  and  Surgeon,  Nov.  1881. 
The  study  of  these  Landmarks  by  both  physi- 


WILSON,  FMASMUS,  F.  Jl.  S. 

A  System  of  Human  Anatomy,  tiencral  iuid  Special.  Edited  by  W.  H. 
Gobrkcht,  M.]).,  ProfeKHf)r  of  (General  and  Surgical  Anntoiny  in  the  Medical  College  of 
Oliio.  In  one  large  and  handsome  octavo  volume  of  016  pages,  with  397  illustrations. 
Cloth,  $4.00;  leather,  $.5.00. 

CLFI^AND,  JOHN,  M,  D.,  F.  R,  S., 

ProfesH'/r  of  Analomj/  and  I'h/Hiologi/  in  Quceii'n  Collegf,  Gaiinai/. 

A  Directory  for  the  Dissection  of  the  Human  Body.  In  one  12mo. 
volume  of  17H  [)age8.     Clotli,  ^1.2."». 


6 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


ALLEN,  SABMISOJV,  M.  J>., 

Professor  oj  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Relations.  For  the  use  of  Practitioners  and  Students  of  Medicine.  With  an  Intro- 
ductory vSection  on  Histology.  By  E.  O.  Shakespeare,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  880 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Section  I.  Hi.?toi.ogy. 
Section  11.  Bones  and  Joints.  Section  III.  Muscles  and  Fascia.  Section  IV. 
Arteries,  Veins  and  Lymphatics.  Section  V.  Nervous  System.  Section  VI. 
Organs  of  Sense,  of  Digestion  and  Genito-Urinary  Organs,  Embryology, 
Development,  Teratology,  Superficial  Anatomy,  Post-Mortem  Examinations, 
AND  General  and  Clinical  Indexes.  Price  per  Section,  $3.50 ;  also  bound  in  one 
volume,  cloth,  $23.00 ;  very  handsome  half  Eussia,  raised  bands  and  open  back,  $25.00. 
For  sale  by  subscription  only.    Apply  to  the  Publishers. 

Extract  from   Introduction. 

It  is  the  design  of  this  book  to  present  the  facts  of  human  anatomy  in  the  manner  best 
suited  to  the  requirements  of  the  student  and  the  practitioner  of  medicine.  The  author 
believes  that  such  a  book  is  needed,  inasmuch  as  no  treatise,  as  far  as  he  knows,  contains,  in 
addition  to  the  text  descriptive  of  the  subject,  a  systematic  presentation  of  such  anatomical 
facts  as  can  be  applied  to  practice. 

A  book  which  will  be  at  once  accurate  in  statement  and  concise  in  terms ;  which  will  be 
an  acceptable  expression  of  the  present  state  of  the  science  of  anatomy ;  which  will  exclude 
nothing  that  can  be  made  applicable  to  the  medical  art,  and  which  will  thus  embrace  all 
of  surgical  importance,  while  omitting  nothing  of  value  to  clinical  medicine, — would  appear 
to  have  an  excuse  for  existence  in  a  country  where  most  surgeons  are  general  practitioners, 
and  whei-e  there  are  few  general  practitioners  who  have  no  interest  in  surgery. 

It  is  to  be  considered  a  study  of  applied  anatomy    care,  and  are  simply  superb.    There  is  as  much 
in  its  widest  sense — a  systematic  presentation  of    of  practical  application  of  anatomical  points  to 


such  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgery.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  travelled  over  by  one  thoroughly  famil- 
iar with  it.    The  illustrations  are  made  with  great 


tlie  every-day  wants  of  the  medical  clinician  as 
to  those'of  the  operating  surgeon.  In  fact,  few 
general  practitioners  will  read  the  worlc  without  a 
feeling  of  surprised  gratitication  that  so  many 
points,  concerning  wliich  they  may  never  have 
thought  before  are  so  well  presented' for  their  con- 
sideration. It  is  a  work  which  is  destined  to  be 
the  best  of  its  kind  in  any  language. — Medical 
Record,  Nov.  25, 1882. 


CLABKE,W,B.,F.M.aS.  &  LOCMWOOD,C,B.,F.B.C.S. 

Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical  School,  London. 
The  Dissector's  Manual.     In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49  illustrations.     Limp  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  4. 


This  is  a  very  excellent  manual  for  the  use  of  the 
student  who  desires  to  learn  anatomy.  The  meth- 
ods of  demonstration  seem  to  us  very  satisfactory. 
There  are  many  woodcuts  which,  for  the  most 


part,  are  good  and  instructive.  The  book  is  neat 
and  convenient.  We  are  glad  to  recommend  it. — 
Boston  Medical  and  Surgical  Journal,  Jan.  17, 1884. 


TBEVJES,  FBJEDJEJBICJK,  F.  B.  C>  So, 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 
Surgical  Applied  Anatomy.     In  one  pocket-size  12mo.  volume  of  540  pages, 
with   61   illustrations.   Limp  cloth,  red   edges,  $2.00.     See  Students'  Series  of  Manuals, 
page  4. 

He  has  produced  a  work  which  will  command  a  I  quickened  by  daily  use  as  a  teacher  and  practi- 
larger  circle  of  readers  than  the  class  for  which  it  tioner,  has  enabled  our  author  to  prepare  a  work 
was  written.  This  union  of  a  thorough,  practical  |  which  it  would  be  a  most  difficult  task  to  excel. — 
acquaintance  with  these  fundamental  branches,  ]  The  American  Practitioner  Feb.  1884. 

CJJBNOW,  JOMW,  M,  J>,,  JF.  B,  C.  B,, 

Professor  of  Anatomy  at  King's  College,  Physician  at  King's  College  Hospital. 
Medical  Applied  Anatomy.     In  one  pocket-size   12mo.  volume.    Preparing. 
See  Students'  Series  of  Manuals,  page  4. 

BELLA3IY,  BDWABn,  F,  B.  C.  S., 

Senior  Assistant-Surgeon  to  the  Charing-Cross  Hospital,  London. 

The  Student's  Guide  to  Surgical  Anatomy:  Being  a  Description  of  the 
most  Important  Surgical  Kegions  of  the  Human  Body,  and  intended  as  an  Introducticm  to 
operative  Surgery.    In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 


HARTSHORNE'S  HANDBOOK  OF  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.    Cloth,  S1.75. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  fevised  and 
modified.  In  two  octavo  volumes  of  1007  pages, 
with  320  woodcuts.    Cloth,  S6.00. 


Lea  Brothers  &  Co.'s  Publications — Physics,  Physiol.,  Anat. 


DMAI'BB,  JOHW  C,  M.  D.,  ii.  !>., 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 

Medical  Physics.  A  Text-book  for  Students  and  Practitioners  of  Medicine.  In 
one  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.   Cloth,  $4. 

From  the  Preface. 

The  fact  that  a  knowledge  of  Physics  is  indispensable  to  a  thorough  understanding  of 
Medicine  has  not  been  as  fully  realized  in  this  country  as  in  Europe,  where  the  admirable 
works  of  Desplats  and  Gariel,  of  Robertson  and  of  numerous  German  writers  constitute  a 
branch  of  educational  literature  to  wliich  we  can  show  no  parallel.  A  full  appreciation 
of  this  the  author  trusts  will  be  sufficient  justification  for  placing  in  book  form  the  sub- 
stance of  his  lectures  on  this  department  of  science,  delivered  during  many  years  at  the 
University  of  the  City  of  New  York. 

Broadly  speaking,  this  work  aims  to  impart  a  knowledge  of  the  relations  existing 
between  Physics  and  Medicine  in  their  latest  state  of  development,  and  to  embody  in  the 
pursuit  of  this  object  whatever  experience  the  author  has  gained  during  a  long  period  of 
teaching  this  special  branch  of  applied  science. 


This  elegant  and  useful  work  bears  ample  testi- 
mony to  the  learning  and  good  judgment  of  the 
author.  He  has  fitted  his  work  admirably  to  the 
exigencies  of  the  situation  by  presenting  the 
reader  with  brief,  clear  and  simple  statements  of 
such  propositions  as  he  is  by  necessity  required  to 
master.  The  subject  matter  is  well  arranged, 
liberally  illustrated  and  carefully  indexed.  That 
it  will  take  rank  at  once  among  the  text-books  is 
certain,  and  it  is  to  be  hoped  that  it  will  find  a 
place  upon  the  shelf  of  the  practical  physician, 
where,  as  a  book  of  reference,  it  will  be  found 
useful  and  agreeable. — Louisville  Medical  News, 
September  26,  18S5. 

Certainly  we  have  no  text-book  as  full  as  the  ex- 
cellent one  he  has  prepared.  It  begins  with  a 
statement  of  the  properties  of  matter  and  energy. 
After  these  the  special  departments  of  physics  are 


explained,  acoustics,  optics,  heat,  electricity  and 
magnetism,  closing  with  a  section  on  electro- 
biology.  The  applications  of  all  these  to  physiology 
and  medicine  are  kept  constantly  in  view.  The 
text  is  amply  illustrated  and  the  many  difficult 
points  of  the  subject  are  brought  forward  with  re- 
markable clearness  and  ability. — Medical  and  Surg- 
ical Reporter,  July  18, 1885.    q. 

That  this  work  will  greatly  facilitate  the  study 
of  medical  physics  is  apparent  upon  even  a  mere 
cursory  examination.  It  is  marked  by  that  scien- 
tific accuracy  which  always  characterizes  Dr. 
Draper's  writings.  Its  peculiar  value  lies  in  the 
fact  that  it  is  written  from  the  standpoint  of  the 
medical  man.  Hence  much  is  omitted  that  ap- 
pears in  a  mere  treatise  on  physical  science,  while 
much  is  inserted  of  peculiar  value  to  the  physi- 
cian.— Medical  Record,  August  22, 1885. 


BOBBBTSON^,  J.  lIcGBEGOB,  M.  A.,  M.  B., 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 

Physiological  Physics.    In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.    Limp  cloth,  $2.00.     See  Students^  Series  of  Manuals,  page  4. 

The  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
ual for  the  student  of  medicine,  an  auxiliary  to 
his  text-book  in  physiology,  and  it  would  be  particu- 
larly useful   as  a  guide  to  his  laboratory  experi- 


ments. It  will  be  found  of  great  value  to  the 
practitioner.  It  is  a  carefully  prepared  book  of 
reference,  concise  and  accurate,  and  as  such  we 
heartily  recommend  it. — Journal  of  the  American 
Medical  Association,  Dec.  6, 1884. 


D ALTON,  JOMW  C,  M.  D., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.     Cloth,  $2. 


Dr.  Dalton's  work  is  the  fruit  of  the  deep  research 
of  a  cultured  mind,  and  to  the  busy  practitioner  it 
cannot  fail  to  be  a  source  of  instruction.  It  will 
inspire  him  with  a  feeling  of  gratitute  and  admir- 
ation for  those  plodding  workers  of  olden  times, 
who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  as  it  now  stands. — New  Orleans 
Melical  and  Surgical  Journal,  Aug.  1885. 

In  the  progress  of  physiological  study  no  fact 
was  of  greater  moment,  none  more  completely 


revolutionized  the  theories  of  teachers,  than  the 
discovery  of  the  circulation  of  the  blood.  This 
explains  the  extraordinary  interest  it  has  to  all 
medical  historians.  The  volume  before  us  is  one 
of  three  or  four  which  have  been  written  within  a 
few  years  by  American  pliysicians.  It  is  in  several 
respects  the  most  complete.  The  volume,  though 
small  in  size,  is  one  of  the  most  creditable  con- 
tributions from  an  American  pen  to  medical  history 
that  has  appeared. — 3Ied.  c&  Surg.  Rep.,  Dec.  C,  1884. 


BELL,  F.  JBFFBBY,  M.  A., 

Professor  of  Comparative  Anato-my  at  Kitirfs  College,  London. 

Comparative  Physiology  and  Anatomy.   In  one  12mo.  volume  of  561  pages, 

with  229  illustrations.   Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  4. 


This  is  another  of  the  "Students'  Series  of 
Manuals,"  and  a  mo.st  excellent  one  at  that.  The 
descriptions  are  clear,  the  illristrations  good,  and 
the  presswork  and   paper  unoxceptionabl'3.    The 


student  of  biology  will  be  materially  benefited  by 
careful  iiivestigation  of  this  valuaMo  little  work. 
— Suulhern  Practitioner,  October,  1885. 


ELLTS,  GBOBGE  VINBB, 

Emeritus  Professor  of  Anatomy  in   University  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowletlge  of  the 
Human  HoHy  by  DisHection.  From  tlie  eiglitli  iunl  rovised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  i)age,s,  witli  249  lllustrationH.    Cloth,  $4.25;  leather,  $5.25. 

BOBEBTS,  JOHN  B„  A,  M.,  M,I>,, 

prof,  of  Applieil  Anat.  and  Oper.  Stirg.  in  Philn,  PolyrJinic  and  Coll.  for  Graduates  in  Medicine. 
The  Compend  of  Anatomy.     For  use  in  the  disHCcting-rooni  and  in  preparing 
for  e.vaininationH.     In  one  IGnio.  volume  of  190  pngcH.     Limp  cloth,  75  cents. 


8        Lea  Brothers  &  Co.'s  Publications — Physiology,  Chemistry. 


DALTOJSr,  JOMW  C,  M,  D., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewritten.  In  one 
very  handsome  octavo  vokime  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00 ;  leather,   $6.00 ;  very  handsome  half  Russia,  raised  bands,  $6.50. 

The  merits  of  Professor  I»alton'.s  text-book,  his  '■  more  oompact  form,  yet  its  delightful  charm  is  re 


smooth  and  pleasing  stj'le,  the  remarkable  clear 
ness  of  his  descrij>tions,  which  leave  not  a  chapter 
obscure,  his  cautious  judgment  and  the  general 
correctness  of  his  facts,  are  perfectly  known.  They 
have  made  his  text'book  the  one  most  familiar 
to  American  students. — Med.  Record,  March  4, 1882. 
Certainly  no  physiological  work  has  ever  issued 
from  the  press  that  presented  its  subject-matter  in 
a  clearer  and  more  attractive  light.  Almost  every 
page  bears  evidence  of  the   exhaustive  revision 


tained,  and  no  subject  is  thrown  into  obscurity. 
Altogether  this  edition  is  far  in  advance  of  any 
previous  one,  and  will  tend  to  keep  the  profession 
posted  as  to  the  most  recent  additions  to  our 
physiological  knowledge. — Michigan  Medical  Neics, 
April,  1882. 

One  can  scarcely  open  a  college  catalogue  that 
does  not  have  mention  of  Dalton's  Physiology  as 
the  recommended  text  or  consultation-book.'  For 
American  students  we  would  unreservedly  recom- 


that  has  taken  place.    The  material  is  placed  in  a  1  mendDr.Dalton'swork.-Fa.ilfed.ilfont/i?j/,July,'82. 


FOSTJEJR,  MICMAEL,  M.  D.,  F.  M.  S., 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.     Third  American  from  the  fourth  English  edition, 
with  notes  and  additions  by  E.  T.  Eeichert,  M.  D.     In  one  handsome  royal  12mo.  volume 
of  908  pages,  with  271  illustrations.  Cloth,  $3.25;  leather,  $3.75.   Just  ready. 


Dr.  Foster's  work  upon  physiology  is  so  well- 
known  as  a  text-book  in  this  country,  thatitneeds 
but  little  to  be  said  in  regard  to  it.  There  is 
scarcely  a  medical  college  in  the  United  States 
where  it  is  not  in  the  hands  of  the  students.  The 
author,  more  than  any  other  writer  with  whom 
we  are  acquainted,  seems  to  understand  what 
portions  of  the  science  are  essential  for  students 


to  know  and  what  maybe  passed  over  by  them  as 
not  important.  From  the  beginning  to  the  end, 
physiology  is  taught  in  a  systematic  manner.  To 
this  third  American  edition  numerous  additions, 
corrections  and  alterations  have  been  made,  so 
that  in  its  present  form  the  usefulness  of  the  book 
will  be  found  to  be  much  increased. —  Cincinnati 
Medical  Kcws,  July  1885. 


FOWEM,  SEWRY,  M.  B.,  F,  M,  C.  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.      In  one  handsome  pocket-size  12mo.  volume  of  396  pages, 
with  47  illustrations.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  3. 


The  prominent  character  of  this  work  is  that  of 
judicious  condensation,  in  which  an  able  and  suc- 
cessful effort  appears  to  have  been  made  by  its 
accomplished  author  to  teach  the  greatest  number 
of  facts  in  the  fewest  possible  words.  The  result 
is  a  specimen  of  concentrated  intellectual  pabu- 
lum seldom  surpassed,  which  ought  to  be  care 


to  every  one  of  our  readers. — The  American  Jour- 
nal of  the  Medical  Sciences,  October,  1884. 

This  little  work  is  deserving  of  the  highest 
praise,  and  we  can  hardlj'  conceive  how  the  main 
facts  of  this  science  could  have  been  more  clearly 
or  concisely  stated.  The  price  of  the  work  is  such 
as  to  place  it  within  the  reach  of  all,  while  the  ex- 


fully  ingested  and  digested  by  every  practitioner    cellenee  of  its  test  will  certainly  secure  for  it  most 
who  desires  to  keep  himself  well  informed  upon    favorable    commendation — Cincinnati  Lancet  and 
this  most  progressive  of  the   medical  sciences.     CH?) ic,. Feb.  IC,  1884. 
The  volume  is  one  which  we  cordially  recommend  t 


CABFFWTFM,  WM,  B.,  M.  D,,  F,  B.  S,,  F.  G,  S,,  F,  i.  8., 

Registrar  to  the  University  of  London,  etc. 

Principles  of  HLiman  Physiology.  Edited  by  Henry  Power,  M.  B.,  Lond., 
F.  E.  C.  S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.  A  new  American  from  the 
eighth  revised  and  enlarged  edition,  with  notes  and  additions  by  Francis  G.  Smith,  M.  D., 
late  Professor  of  the  Institutes  of  Medicine  in  the  University  of  Pennsylvania.  In  one 
very  large  and  handsome  octavo  volume  of  1083  pages,  with  two  plates  and  373  illus- 
trations.   Cloth,  $5.50 ;  leather,  $6.50 ;  half  Russia,  $7, 


SIMON,  W.,  Ph,  !>.,  M.  2>., 

Professor  of  Chemistry  and  Toxicology  in  the   College  of  Physicians  and  Surgeons,  Baltimore,  and 

Professor  of  Chemistry  in  the  Maryland  College  of  Pharmacy. 
Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
In  one  8vo.  vol.  of  410  pp.,  M'itli  16  woodcuts  and  7  plates,  mostly  of  actual  deposits, 
with  colors  illustrating  56  of  the  most  important  chemical  reactions.  Cloth,  $3.00 ;  also 
without   plates,   cloth,  $2.50. 


This  book  supplies  a  want  long  felt  bj'  students 
of  medicine  and  pharmacy,  and  is  a  concise  but 
thorough  treatise  on  the  suDject.  The  long  expe- 
rience of  the  author  as  a  teacher  in  schools  of 
medicine  and  pharmacy  is  conspicuous  in  the 
perfect  adaptation  of  the  work  to  the  special  needs 
of  the  student  of  these  branches.     The  colored 


plates,  beautifully  executed,  illustrating  precipi- 
tates of  various  reactions,  form  a  novel  and  valu- 
able feature  of  the  book,  and  cannot  fail  to  be  ap- 
preciated by  both  student  and  teacher  as  a  help 
over  the  hard  places  of  the  science. — Maryland 
Medical  Journal,  Nov.  22,  1884. 


Wohler's  Outlines  of  Organic  Chemistry.    Edited  by  Fittig.    Translated 
by  Ira  Eemsen,  M.  D.,  Ph.  D.     In  one  12mo.  volume  of  550  pages.     Cloth,  $3. 


GALLOWAY'S  QUALITATIVE  ANALYSIS. 

LEHMANN'S  MANUAL  OF  CHEMICAL  PHYS- 
IOLOGY. In  one  octavo  volume  of  327  pages, 
with  41  illustrations.    Cloth,  $2.25. 


CAKPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 
Abuse  or  Alcoholic  Liquors  in  Health  and  Dis- 
ease. With  explanationsof  scientific  words.  Small 
12mo.    178  pages.    Cloth,  60  cents. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


9 


FOWNES,  GMOBGE,  JPh.  JD. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em- 
bodying Watts'  Inorganic  Ohemistry.  New  American  edition.  In  one  large  royal  12mo. 
volume  of  1061  pages,  with  168  illustrations  on  wood  and  a  colored  plate.  Cloth,  |2.75 ; 
leather,  $3.25. 


Fownes'  Chemistry  has  been  a  standard  text- 
book upon  chemistry  for  many  years.  Its  merits 
are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.      It  has  steadily 


chemistry  extant. — Oincinnati  Medical  News,  Oc- 
tober, 1885. 

Of  all  the  works  on  chemistry  intended  for  the 
use  of  medical  students,  Fownes'  Chemistry  is 
perhaps  the  most  widely  used.  Its  popularity  is 
based  upon  its  excellence.  This  last  edition  con- 
tains all  of  the  material  found  in  the  previous. 


maintained  its  position  as  a  text-book  with  medi-  and  it  is  also  enriched  by  the  addition  of  Watts' 
cal  students.  In  this  work  are  treated  fully:  Heat,  I  Physiral  and  Inorganic  Chemistry.  All  of  the  mat- 
Light  and  Electricity,  including  Magnetism.  The  I  ter  is  brought  to  the  present  standpoint  of  chemi- 
influenee  exerted  by  these  forces  in  chemical  I  cal  knowledge.  We  may  safely  predict  for  this 
action  upon  health  and  disease,  etc.,  is  of  the  most  |  work  a  continuance  of  the  fame  and  favor  it  enjoys 
important  kind,  and  should  be  familiar  to  every  I  among  medical  students. — New  Orleans  Medical 
medical  practitioner.  We  can  commend  the  and Sfsrf/icaJ  JbM?-naZ,  March,  1886. 
work  as  one  of  the   very  best  text-books    upon  i 


FBANKJLANJy,  E.,  D.  C.  L.,  F.B.S.,  &JAJPP,  F,  M.,  F,  I,  C, 


Professor  of  Chemistry  in  the  Normal  School 
of  Science,  London. 


Assist.  Prof,  of  Chemistry  in  the  Normal 
School  of  Science,  London. 


Inorganic  Claemistry.     In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  lithographic  plates.     Cloth,  $3.75  ;  leather,  $4.75. 

This  work  should  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certainly  better 
adapted  than  any  work  upon  chemistry,with  which 
we  are  acquainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med- 
icine should  have.    Physicians  who  feel  that  their 


chemical  knowledge  is  behind  the  times,  would 
do  well  to  devote  some  of  their  leisure  time  to  the 
study  of  this  work.  The  descriptions  and  demon- 
strations are  made  so  plain  that  there  is  no  diffi- 
cultj'  in  understanding  them. — Cincinnati  Medical 
News,  January,  1886. 


ATTFIELJD,  JOHN,  Fh.  J)., 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  etc. 

Chemistry,  General,  Medical  and  Pharmaceutical ;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  tenth 
English  edition,  specially  revised  by  the  Author.  In  one  handsome  royal  12mo.  volume 
of  728  pages,  with  87  illustrations.     Cloth,  $2.50 ;  leather,  $3.00. 

A  text-book  which  passes  through  ten  editions  [  to  put  himself  in  the  student's  place  and  to  appre- 
in  sixteen  years  must  have  good  qualities.  This 
remark  is  certainly  applicable  to  Attfield's  Chem- 
istry, a  book  which  is  so  well  known  that  it  is 
hardly  necessary  to  do  more  than  note  the  appear- 
ance of  this  new  and  improved  edition.  It  seems, 
however,  desirable  to  point  out  that  feature  of  the 
book  which,  in  all  probability,  has  made  it  so 
popular.  There  can  be  little  doubt  that  it  is  its 
thoroughly  practical  character,  the  expression 
being  used  in  its  best  sense.  The  author  under- 
stands what  the  student  ought  to  learn,  and  is  able 


ciate  his  state  of  mind. — American  Chemical  'J'ovi/r- 
nal,  .^pril,  1884. 

It  is  a  book  on  which  too  much  praise  cannot  be 
bestowed.  As  a  text-book  for  medical  schools  it 
is  unsurpassable  in  the  present  state  of  chemical 
science,  and  having  been  prepared  with  a  special 
view  towards  medicine  and  pharmacy,  it  is  alike 
indispensable  to  all  persons  engaged  in  those  de- 
partments of  science.  It  includes  the  whole 
chemistry  of  the  lastPharmacopcsia.— JPaci/ic  Medi- 
cal and  Sugrical  .Journal,  Jan.  1884. 


BLOXA3I,  CMAJRLES  L., 

Professor  of  Chemistry  in  King''s  College,  London. 


New  American  from  the  fifth  Lon- 
handsome  octavo 


Chemistry,  Inorganic  and  Organic 

don   edition,   thoroughly  revised   and  much   improved.     In  one  very  ha 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $3.75  ;  leather,  $4.75. 
Comment  from  us  on  this  standard  work  is  al-    complain  that  chemistry  is  a  hard  study.    Much 

attention  is  paid  to  exjierimental  illustrations  of 


most  superfluous.  It  differs  widely  in  scope  and 
aim  from  that  of  Attfield,  and  in  its  way  is  equally 
beyond  criticism.    It  adopts  the  most  direct  meth- 


chemical    principles    and    phenomena,    and  the 
mode  of  conducting  these  experiments.    The  book 


ods  in  stating  the  principles,  hypotheses  and  facts    maintains  the  position  it  has  always  held  as  one  of 
of  the  science.    Its  language  is  so  terse  and  lucid,    the  best  manuals  of  general  chemistry  in  the  Eng- 
and  Its  arrangement  of  matter   so  logical  in  se-    lish  language.— i)efroti  Lancet,  Feb.  1884. 
quence  that  the  .student  never    has  occasion  to  | 

liEMSEN,  IBA,  Wri}.,  Fh.  !>., 

Professor  of  Chemist ry  in  the  Johns  Hopkins  University,  Baltimore. 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.  Second  and  revised  edition.  In  one  handsome  royal  12mo. 
volume  of  240  pages.     Cloth,  $1.75. 

That  in  ho  few  years  a  second  edition  haH  I  assures  its  accuracy  in  all  matters  of  fact,  and  its 
been  called  for  indicaten  that  many  chemical  j  Judicious  conservatism  in  matters  of  theory,  com- 
teachers  have  been  found  ready  to  endorse  its  i  bined  with  the  fulness  with  which.  In  a  small 
plan  and  to  adopt  its  methodH.  In  this  edition  compass,  the  present  attitude  of  chemical  science 
a  oonHidcrable  proportion  of  the  book  haH  been  ;  tf)vvards  the  conHtitution  of  compounds  in  con- 
rewritten,  much  new  matter  has  been  added  ]  Hidered.glvesita  value  much  beyond  thataccorded 
and  the  whole  has  been  brought  up  to  date.  '  to  the  average  textrbookH  of  the  Aay.— American 
Wp  earnestly  commend  this  book  to  every  student  .lournnl  oj  Science,  March,  1884. 
of  chemistry.    The  high  reputation  of  the  autlior    . 


10 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


CBlABLES,  T.  CBAJSrSTOVJSf,  M.  D.,  F.  C.  S,,  M.  S., 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen^s  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.  A 
Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
Nutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  tlie  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pi-e- 
paring  or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  with  38  woodcuts  and  1  colored  plate.     Cloth,  553.50. 


The  work  is  thoroughly  trustworthy,  and  in- 
formed throughout  by  a  genuine  scientific  spirit. 
The  author  deals  with  the  chemistry  of  the  diges- 
tive secretions  in  a  systematic  manner,  which 
leaves  nothing  to  be  desired,  and  in  reality  sup- 
plies a  want  in  English  literature.  The  book  ap- 
pears to  us  to  be  at  once  full  and  systematic,  and 
to  show  a  just  appreciation  of  the  relative  import- 
ance of  the  various  subjects  dealt  with. — British 
Medical  Journal,  November  29, 1884. 


Dr.  Charles'  manual  admirably  fulfils  its  inten- 
tion of  giving  his  readers  on  the  one  hand  a  sum- 
mary, comprehensive  but  remarkably  compact,  of 
the  mass  of  facts  in  the  sciences  which  have  oe- 
come  indispensable  to  the  physician  ;  and,  on  the 
other  hand,  of  a  system  of  practical  directions  so 
minute  that  analyses  often  considered  formidable 
may  be  pursued  by  any  intelligent  person. — 
Archives  of  Medicine,  Dec.  1884. 


HOFFMANN,  F,,  A,M.,  ni,iy.,   &  FOWFJR  F.B,,  Fh.JD., 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chem.  in  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.  Cloth,  |4.2o. 
We  congratulate  the  author  on  the  appearance  i  tion  of  them  singularly  explicit.    Moreover,  it  is 


of  the  third  edition  of  this  work,  published  for  the 
first  time  in  this  country  also.  It  is  admirable  and 
the  information  it  undertakes  to  supply  is  both 
extensive  and  trustworthy.  The  selection  of  pro- 
cesses for  determining  the  purity  of  the  substan- 
ces of  which  it  treats  is  excellent  and  the  descrip- 


exceptionally  free  from  typographical  errors.  We 
have  no  hesitation  in  recommending  it  to  those 
who  are  engaged  either  in  the  manufacture  or  the 
testing  of  medicinal  chemicals. — London  Pharma- 
ceutical Journal  and  Transactions,  1883. 


CLOWES,  FRANK,  D.  Sc,  London, 

Senior  Science-Master  at  the  High  School,  Newcastle-wnder-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  very  handsome  royal  12mo.  volume  of  387  pages,  with  55  illustrations.  Cloth, 
§2.50. 

The  style  is  clear,  the  language  terse  and  vigor-  and  text  book. — Medical  Record,  July  18, 1885. 
ous.  Beginning  with  a  list  of  apparatus  necessary  We  may  simply  repeat  the  favorable  opinion 
for  chemical  work,  he  gradually  unfolds  the  sub-  which  we  expressed  after  the  examination  of  the 
ject  from  its  simpler  to  its  more  complex  divisions,  previous  edition  of  this  work.  It  is  practical  in  its 
It  is  the  most  readable  book  of  the  kind  we  have  aims,  and  accurate  and  concise  in  its  statements, 
yet  seen,  and  is  without  doubt  a  systematic,  — American  Journal  of  Pharmacy,  k\x^ViSi,\?i9ib. 
intelligible  and  fully  equipped  laboratory  guide 


RALFF,  CMARLFS  H.,  M.  D.,  F.  B.  C.  F., 

Assistant  Physician  at  the  London  Hospital. 
Clinical  jDhemistry.     In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 


illustrations.  Limp  cloth,  red  edges,  §1.50, 
This  is  one  of  the  most  instructive  little  works 
that  we  have  met  with  in  a  long  time.  The  author 
is  a  physician  and  physiologist,  as  well  as  a  chem- 
ist, consequently  the  book  is  unqualifiedly  prac- 
tical, telling  the  physician  just  what  he  ougnt  to 
know,  of  the  applications  of  chemistry  in  medi- 


See  Students'  Series  of  Manuals,  page  4. 
cine.  Dr.  Ralfe  is  thoroughly  acquainted  with  the 
latest  contributions  to  his  science,  and  it  is  quite 
refreshing  to  find  the  subject  dealt  with  so  clearly 
and  simply,  yet  in  such  evident  harmony  with  the 
modern  scientific  methods  and  spirit. — Medical 
Record,  February  2, 1884. 


CLASSEN,  ALEXANDER, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 
Elementary  Quantitative  Analysis.     Translated,  with  notes  and  additions,  by 
Edgar  F.  Smith,  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.     In  one  12mo.  volume  of  324  pages,  with  36  illust.     Cloth,  §2.00. 

and  then  advancing  to  the  analysisof  minerals  and 
such  products  as  are  met  with  in  applied  chemis- 
try. It  is  an  indispensable  book  for  students  in 
chemistry. — Boston  Journal  of  Chemistry,  Oct.  1878. 


It  is  probably  the  best  manual  of  an  elementary 
nature  extant  insomuch  as  its  methods  are  the 
best.  It  teaches  by  examples,  commencing  with 
single   determinations,    followed  by  separations. 


GREENE,  WLLLLAM  H.,  M,  L>,, 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 
A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  Based  upon  Bow- 
man's Medical  Chemistry.  In  one  12mo.  volume  of  310  pages,  with  74  illus.  Cloth,  §1.75. 
It  is  a  concise  manual  of  three  hundred  pages,  '■  the  recognition  of  compounds  due  to  pathological 
giving  an  excellent  summary  of  the  best  methods  |  conditions.  The  detection  of  poisons  is  treated 
of  analyzing  the  liquids  and  solids  of  the  body,  both  i  with  sufficient  fulness  for  the  purpose  of  thestu- 
forthe  estimation  of  their  normal  constituents  and-  |  dent  or  practitioner. — Boston  Jl.  of  CTew.,  Junp,'80. 


Lea  Brothers  &  Co.'s  Publications — Pharm.,  Mat.  Med.,  Therap.  11 


BMUJVTOW,  T.  LAVDBR,  M.JD.,  D.Sc,  F.It.S,,  JF.B.C.I^., 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  London,  etc. 

A  Text-book  of  Phai'macology,  Therapeutics  and  Materia  Medica ; 

Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
In  one  handsome  octavo  volume  of  1033  pages,  with  188  illustrations.  Cloth,  $5.50 ; 
leather,  §6.50.     Just  ready. 

It  is  a  scientific  treatise  worthy  to  be  ranked  with  '  Dr.  Brunton  has  been  building  up  the  material 
the  highest  productions  in  physiology,  either  in  i  for  this  volume  through  sixteen  years  of  steady 
our  own  or  any  other  language.  Everything  is  ;  labor,  and  the  result  proves  that  this  long  toil  was 
practical,  the  dty,  hard  facts  of  physiology  being  '  well  directed.  He  has  produced  a  work  of  singu- 
pressed  into  service  and  applied  to  the  treatment  ,  lar  merit,  every  page  of  which  is  marked  by  the 
of  the  commonest  complaints.  The  information  i  results  of  original  research,  judiciously  analyzed. 
is  so  systematically  arranged  that  it  is  available  I  We  are  not  saying  too  much  in  pronouncing  this 


for  immediate  use.  The  index  is  so  carefully 
compiled  that  a  reference  to  any  special  point  Is  | 
at  once  obtainable.  Dr.  Brunton  is  never  satisfied  j 
with  vague  generalities,  but  gives  clear  and  pre-  j 
ci.se  directions  for  prescribing  the  various  drugs  ' 
and  preparations.  We  congratulate  students  on 
being  at  last  placed  in  possession  of  a  scientific 
treatise  of  enormous  practical  Importance. — The 
London  Lancet,  June  27,  1885. 


treatise  the  most  complete  and  valuable  in  ourown 
or  any  other  language  on  the  topic  to  which  it  is 
devoted.  The  arrangement  is  eminently  scientific. 
The  author  is  equally  satisfactory  in  all  his  details, 
and  his  work  is  certainly  destined  to  rank  as  one 
of  the  most  important  additions  to  medical  litera- 
ture of  the  period. — Medical  and  Surgical  Reporter, 
Oct.  17,  1885. 


pahmisjs,  bdward, 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 

A  Treatise  on  Pharmacy :    designed  as  a  Text-book  for  the  Student,  and  as  a 

Guide  for  the  Physician  and  Pharmaceutist.     With  many  Formulae  and   Prescriptions. 

Fifth  edition,  thoroughly  revised,  by  Thomas  S.  WrEGAND,  Ph.  G.      In  one  handsome 

octavo  volume  of  1093  pages,  with  256  illustrations.     Cloth,  $5  ;  leather,  §6. 

No  thoroughgoing  pharmacist  will  fail  to  possess  j  Each  page  bears  evidence  of  the  care  "bestowed 


himself  of  so  useful  a  guide  to  practice,  and  no 
physician  who  properly  estimates  the  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most eflfective  meth- 
ods of  combination  are  concerned,  can  afford  to 
leave  this  work  out  of  the  list  of  their  works  of 
reference.  The  country  practitioner,  who  must 
always  be  in  a  measure  his  own  pharmacist,  will 
find  it  indispensable. — Louisville  Medical  News, 
March  29,  18S-i. 

This  well-known  work  presents  itself  now  based 
upon   the    recently  revised  new    Pharmacopceia. 


upon  it,  and  conveys  valuable  information  from 
the  rich  store  of  the  editor's  experience.  In  fact, 
all  that  relates  to  practical  pharmacy — apparatus, 
processes  and  dispensing — has  been  arranged  and 
described  with  clearness  in  its  various  aspects,  so 
as  to  aflford  aid  and  advice  alike  to  the  student  and 
to  the  practical  pharmacist.  The  work  is  judi- 
ciously illustrated  with  good  woodcuts — American 
Journal  of  Pharmacii,  .January,  1884. 

There  is  nothing  to  equal  Parrish's  Pharmacy 
in  this  or  any  other  language. — London  Pharma- 
ceutical Journal. 


HBMlIAJSnsr,  Dr.  L., 

Professor  of  Physiology  in  the  University  of  Zurich. 

Experimental  Pharmacology.  A  Handbook  of  Methods  for  Determining  the 
Physiological  Actions  of  Drugs.  Translated,  with  the  Author's  permission,  and  with 
extensive  additions,  by  Egbert  Meade  Smith,  M.  D.,  Demonstrator  of  Physiology  in  the 
University  of  Pennsylvania.  In  one  handsome  12mo.  volume  of  199  pages,  with  32 
illustrations.     Cloth,  $1.50. 

MAISCH,  JOSJVM.,  JPhar.  JX, 

Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  New  (second)  edition.  In  one  handsome  royal  12mo.  volume  of  526 
pages,  with  242  illu.strations.     Cloth,  $3.00. 

This  work  contains  the  substance, — the  practical  j  excellent,  being  very  true  to  nature,  and  are  alone 
"kernel  of  the  nut"  picked  out,  so  that  the  stu-  worth  the  price  of  the  book  to  the  student.  To  the 
dent  has  no  superfluous  labor.  He  can  confidently  practical  physician  and  pharmacist  it  is  a  valuable 
accept  what  this  work  places  before  him,  without  work  for  handy  reference  and  for  keeping  fresh 
any  fear  that  the  gist  of  the  matter  is  not  in  it.  !  in  the  memory  the  knowledge  of  materia  medica 
Another  merit  is  that  the  drugs  are  placed  before  I  and  botany  already  acquired.  We  can  and  do 
hira  in  such  a  manner  as  to  simplify  very  much  i  heartily  recommend  it— Medical  and  Surgical  Re- 
the  .study  of  them,  enabling  the  mind  to  grasp  i  porter,  Feb.  14,  1885. 
them  more  readily.    The  illustrations  are  most  | 

BRUCE,  J.   MITCHELL,  M,  D.,  F.  JR,  C.  P., 

F'hyHician  awl  Lecturer  on  Mnlerm  Meriica  and  Therapeutics  at  Charing  Cross  Hospital,  London. 
Materia    Medica   and  Therapeutics.     An  Introduction   to   Kational  Treat- 
ment,    in  one  pocket-size  12mo.  volume  of  555  pages.     Limp  cloth,  $1.50.     See  Students' 
Series  of  Manv/iln,  page  4. 

GltlEFITH,  JROBERT  EGLESFIELD,  M.  D. 

A  Universal  Formulary,  containing  the  Metliods  of  Preparing  and  Adminis- 
tering Oflicinal  and  other  Medicines.  Tlie  whole  adapted  to  I-'hy.siclans  and  Pharmaceut- 
ists. Third  edition,  thorouglily  revised,  with  numerous  additions,  by  .loiiN  M.  Maisch, 
Phar.  I).,  Profe«.sf>r  of  Materia  Medica  and  Botany  in  the  Philiulel[)hia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  pages,  with  38  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 


12         Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therap. 
STILIjM,  a,,  M.  2).,  LL.  D.,  &  MAISCH,  J,  M,,  Phar,  !>., 

Professor  Emeritus  of  the  Theory  and  Prac-  Prof,  of  Mat.  Med.  and  Botany  in  Phila. 

tice  of  Medicine  and  of  Clinical  Medicine  College  of  Pharmacy,  Sec'y  to  the  Ameri- 

in  the   University  of  Pennsylvania.  can  Pharmaceutical  Association. 

The  National  Dispensatory :  Containing  the  Natural  History,  Chemistry,  Phar- 
macy, Actions  and  Uses  of  Medicines,  including  those  recognized  in  the  Pharmacopoeias  of 
the  United  States,  Great  Britain  and  Germany,  with  numerous  references  to  the  French 
Codex.  Third  edition,  thoroughly  revised  and  greatly  enlarged.  In  one  magnificent 
imperial  octavo  volume  of  1767  pages,  with  311  tine  engravings.  Cloth,  |7.2o ; 
leather,  $8.00 ;  half  Russia,  open  back,  $9.00.  With  Denison's  "  Ready  Reference  Index  " 
$1.00  in  addition  to  price  in  any  of  above  styles  of  binding. 

In  the  present  revision  the  authors  have  labored  incessantly  with  the  view  of  making 
the  third  edition  of  Tpie  National,  Dispensatory  an  even  more  complete  represen- 
tative of  the  pharmaceutical  and  therapeutic  science  of  1884  than  its  first  edition  was  of 
that  of  1879.  For  this,  ample  material  has  been  afforded  not  only  by  the  new  United 
States  Pharmacopceia,  but  by  those  of  Germany  and  France,  which  have  recently  appeared 
and  have  been  incorporated  in  the  Dispensatory,  together  with  a  large  number  of  new  non- 
officinal  remedies.  It  is  thus  rendered  the  representative  of  the  most  advanced  state  of 
American,  English,  French  and  German  pharmacology  and  therapeutics.  The  vast  amount 
of  new  and  imiaortant  material  thus  introduced  may  be  gathered  from  the  fact  that  the 
additions  to  this  edition  amount  in  themselves  to  the  matter  of  an  ordinary  full-sized  octavo 
volume,  rendering  the  work  larger  by  twenty-five  per  cent,  than  the  last  edition.  The 
Therapeutic  Index  (a  feature  peculiar  to  this  work),  so  suggestive  and  convenient  to  the 
practitioner,  contains  1600  more  references  than  the  last  edition — the  General  Index 
3700  more,  making  the  total  number  of  references  22,390,  while  the  list  of  illustrations 
has  been  increased  by  80.  Every  effort  has  been  made  to  prevent  undue  enlargement  of 
the  volume  by  having  in  it  nothing  that  could  be  regarded  as  superfluous,  yet  care  has 
been  taken  that  nothing  should  be  omitted  which  a  pharmacist  or  physician  could  expect 
to  find  in  it. 

The  appearance  of  the  work  has  been  delayed  by  nearly  a  year  in  consequence  of  the 
determination  of  thfe  authors  that  it  should  attain  as  near  an  approach  to  absolute  ac- 
curacy as  is  humanly  possible.  With  this  view  an  elaborate  and  laborious  series  of 
examinations  and  tests  have  been  made  to  verify  or  correct  the  statements  of  the  Pharma- 
copoeia, and  very  ruimerous  corrections  have  been  found  necessary.  It  has  thus  been  ren- 
dered indispensable  to  all  who  consult  the  Pharmacopoeia. 

The  work  is  therefore  presented  in  the  full  expectation  that  it  will  maintain  the 
position  universally  accorded  to  it  as  the  standard  authority  in  all  matters  pertaining  to 
its  subject,  as  registering  the  furthest  advance  of  the  science  of  the  day,  and  as  embody- 
ing in  a  shape  for  convenient  reference  the  recorded  results  of  human  experience  in  the 
laboratory,  in  the  dispensing  room,  and  at  the  bed-side. 

Comprehensive  in  scope,  vast  in  design   and    up  to  date.    The  work  has  been  very  well  done,  a 
splendid  in  execution,  The  Na,tional  Dispensatory    large  number  of   extra-pharmacopoeial  remedies 


may  be  justly  regarded  as  the  most  important  work 
of  its  kind  extant. — Louisville  Medical  Neivs,  Dec, 


having  been  added  to  those  mentioned  in  previous 
editions. — London  Lancet,  Nov.  22, 1884. 


6, 1884.  I      Its  completeness  as  to  subjects,  the  comprehen- 

We  have  much  pleasure  in  recording  the  appear-  1  siveness  of  its  descriptive  language,  the  thorough- 


ance  of  a  third  edition  of  this  excellent  work  of 
reference.  It  is  an  admirable  abstract  of  all  that 
relates  to  chemistry,  pharmacy,  materia  medica, 
pharmacology  and  therapeutics.  It  may  be  re- 
garded as  embodying  the  Pharmacopceias  of  the 
civilized  nations  of  the  world,  all  being  brought 


ness  of  the  treatment  of  the  topics,  its  brevity  not 
sacrificing  the  desirable  features  of  information 
for  which  such  a  work  is  needed,  make  this  vol- 
ume a  marvel  of  excellence. — Pharmaceutical  Re- 
cord, Aug.  15, 1884. 


FAItQVHAJEtSOW,  MOBJEMT,  M.  J>., 

Lecturer  on  Materia  Medica  at  St.  Mary^s  Hospital  Medical  School. 

A  Guide  to  Therapeutics  and  Materia  Medica.  Third  American  edition, 
specially  revised  by  the  Author.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopceia  by 
Frank  Woodbury,  M.  D.  In  one  handsome  12mo.  volume  of  524  pages.  Cloth,  $2.25. 
Dr.  Farquharson's  Therapeutics  is  constructed  i  umned  pages — one  side  containing  the  recognized 
upon  apian  vrhich  brings  before  the  reader  all  the  ,  physiological  action  of  the  medicine,  and  the  other 
essential  points  with  reference  to  the  properties  of  !  the  disease  in  which  observers  (who  are  nearly  al 


drugs.  It  impresses  these  upon  him  in  such  a  way 
as  to  enable  him  to  take  a  clear  view  of  the  actions 
of  medicines  and  the  disordered  conditions  in 
which  they  must  prove  useful.    The  double-col- 


ways  mentioned)  have  obtained  from  it  good  re- 
sults— make  a  very  good  arrangement.  The  early 
chapter  containing  rules  for  prescribing  is  excel- 
lent.— Canada  Med.  and  Surg.  Journal,  Dec.  1882. 


JEDJES,  BOBJEBT  T.,  31.  D., 

Jackson  Professor  of  Clinical  Medicine  in  Harvard  University,  Medical  Department. 

A  Text-Book  of  Materia  Medica  and  Therapeutics.  In  one  octavo  volume 
of  about  600  pages,  with  illustrations.     Preparing. 

STILLJE,  ALFBEJD,  M.  D.,  LL.  J)., 

Professor  of  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 

Therapeutics  and  Materia  Medica.  A  Systematic  Treatise  on  the  Action  and 
Uses  of  Medicinal  Agents,  including  their  Description  and  History.  _  Fourth  edition,, 
revised  and  enlarged.  In  two  large  and  handsome  octavo  volumes,  containing  1936  pages.. 
Cloth,  $10.00 ;  leather,  $12.00  ;  very  handsome  half  Russia,  raised  bands,  $13.00. 


Lea  Brothers  &  Co.'s  Publications — Pathol.,  Histol. 


13 


COATS,  JOSBPS,  M.  D.,  F, 

Pathologist  to  the  Glasgoiv  Western  Infirmary. 

A  Treatise  on  Pathology.    In  one 

with  339  beautiful  illustrations.     Cloth,  |5.50 

The  work  before  us  treats  the  subject  of  Path- 
ology more  extensively  than  it  is  usually  treated 
in  similar  works.  Medical  students  as  well  as 
physicians,  who  desire  a  work  for  study  or  refer- 
ence, that  treats  the  subjects  in  the  various  de- 
partments in  a  very  thorough  manner,  but  without 
prolixity,  will  certainly  give  this  one  the  prefer- 
ence to  any  with  which  we  are  acquainted.  It  sets 
forth  the  most  recent  discoveries,  exhibits,  in  an 
interesting  manner,  the  changes  from  a  normal 


F,  F.  S,, 

very  handsome  octavo  volume  of  829  pages, 
;  leather,  |6.50. 

condition  effected  in  structures  by  disease,  and 
points  out  the  characteristics  of  various  morbid 
agencies,  so  that  they  can  be  easily  recognized.  But, 
not  limited  to  morbid  anatomy,it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions.  There  is  nothing  belonging  to  its  de- 
partment of  medicinp  that  is  not  as  fully  elucidated 
as  our  present  knowledge  will  admit.— Cincinnati 
Medical  News,  Oct.  1883. 


Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Cross  Hospital  Medical  School,  London. 
Pathology  and  Morbid  Anatomy.     Fifth  American  from  the  sixth  revised 
and  enlarged  English  edition.     In  one  very  handsome  octavo  volume  of  482  pages,  with 
150  fine  engravings.     Cloth,  $2.50. 


The  fact  that  this  well-known  treatise  has  so 
rapidly  reached  its  sixth  edition  is  a  strong  evi- 
dence of  its  popularity.  The  author  is  to  be  con- 
gratulated upon  the  thoroughness  with  which  he 
has  prepared  this  work.  It  is  thoroughly  abreast 
with  all  the  most  recent  advances  in  pathology. 


No  work  in  the  English  language  is  so  admirably 
adapted  to  the  wants  of  the  student  and  practi- 
tioner as  this,  and  we  would  recommend  it  most 
earnestly  to  every  one. — Nashville  Journal  of  Medi- 
cine and  Surgery,  Nov.  1884. 


WOODHEAD,  G.  SIMS,  M.  D,,  F,  M.  C,  P,  E., 

Demonstrator  of  Pathology  in  the  University  of  Edinburgh. 
Practical  Pathology.     A  Manual  for  Students  and  Practitioners.     In  one  beau- 
tiful octavo  volume  of  497  pages,  with  136  exquisitely  colored  illustrations.     Cloth,  $6.00. 

themselves  with  this  manual.  The  numerous 
drawings  are  not  fancied  pictures,  or  merely 
schematic  diagrams,  but  they  represent  faithfully 


It  forms  a  real  guide  for  the  student  and  practi- 
tioner who  is  thoroughly  in  earnest  in  his  en- 
deavor to  see  for  himself  and  do  for  himself.  To 
the  laboratory  student  it  will  be  a  helpful  com- 
panion, and  all  those  who  may  wish  to  familiarize 
themselves  with  modern  methods  of  examining 
morbid  tissues    are    strongly  urged   to   provide 


the  actual  images  seen  under  the  microscope. 
The  author  merits  all  praise  for  having  produced 
a  valuable  work. — Medical  Record,  May  31, 1884. 


SCHAFEM,  EDWAMD  A.,  F.  M.  S., 

Assistant  Professor  of  Physiology  in  University  College,  London. 
The  Essentials  of  Histology.  In  one  octavo  volumfe  of  246  pages,  with 
281  illustrations.  Cloth,  $2.25.  Just  ready. 
This  admirable  work  is  a  cheering  example  of 
well-won  success,  earned  by  the  faithful  and  dili- 
gent pursuit  of  excellence  in  presentation  of  this 
essential  foundation  of  all  true  medical  science. 
Since  this  new  work  of  Professor  Schafer's  will 
doubtless  be  speedily  placed  upon  the  list  of  text- 
books required  in  every  medical  college,  we  feel 
that  it  needs  no  further  recommendation  at  our 
hands. — Am.  Jour,  of  the  Med.  Sciences,  Jan.  1886. 


This  short  volume  might  be  called  a  companion 
book  to  Green's  Pathology,  and  fills  the  same  place 
in  histology  the  latter  occupies  in  pathology.  This 
book  is  so  short,  clear  and  satisfactory,  as  to  invite 
perusal,  and  repay  any  time  spent  in  doing  so.  We 
think  the  book  deserving  of  the  highest  praise. 
— New  Orleans  Medical  atid  Surgical  Journal,  Dec. 
1885. 


COBJVIJL,  v.,  and  BAJSTIEn,  X., 

Prof,  in  the  Faculty  of  Med.  of  Paris.  Prof,  in  the  College  of  Prance. 

A  Manual  of  Pathological  Histology.  Translated,  with  notes  and  additions, 
by  E.  O.  Shakespeare,  M.  D.,  Pathologist  and  Ophthalmic  Surgeon  to  Philadelphia 
Hospital,  and  by  .J.  Henry  C.  Simes,  M.  D.,  Demonstrator  of  Pathological  Histology  in 
the  University  of  Pennsylvania.  In  one  very  handsome  octavo  volume  of  800  pages,  with 
360  illustrations.    Cloth,  $5.50  ;  leather,  $6.50 ;  half  Russia,  raised  bands,  $7. 

KLEIN,  E.,  M.  D.,  J^.  jK.  S,, 

Joint  Lecturer  on  General  Anat.  and  Phys.  in  the  Med.  School  of  St.  Bartholomew's  Hasp.,  London. 
Elements  of  Histology.    In  one  pocket-size  12mo.  volume  of  360  pages,  with  181 
illus.    Limp  cloth,  red  edges,  $1.50.     See  Students'  Series  of  Manuals,  page  4. 

Although  an  elementary  work,  it  is  by  no  means    The  illustrations  are  numerous  and  excellent.    We 
superficial  or  incomplete,  for  the  author  presents    commend  Dr.  Klein's  Elements  most  heartily  to 
in  concise  language  nearly  all  the  fundamental  facts    the  stadeat.— Medical  Record,  Dec.  1, 1883. 
regarding  the  microscopic  structure  of  tissues. 


FEFFElt,  A.  J,,  M,  B,,  M.  S.,  F,  M.  C,  S,, 

Surgeon  and  Lecturer  at  St.  Mary's  Hospital,  London. 


Surgical  Pathology.     In  one  jjocket-size  12mo.  volume  of  511  pages,  with  81 
nations.  Linipcloth,re(i  edges,  $2.00.     Hee  Stvdentu^  Series  of  Manuals, 


illust 

It  is  not  prelentiouH,  but  It  will  serve  exceed- 
ingly well  as  a  hook  of  reference.  It  embodif^s  a 
great  deal  of  matter,  extending  over  the  whole 
field  of  surgical  pathology.  Its  form  in  practical, 
its  language  Is  clear,  and  the  Information  set 
forth    is    well-arranged,    well-Indexed   and  well- 


page  4. 

illustrated.  The  student  will  find  in  it  nothing 
that  Is  unnecessary.  The  list  of  sublects  covers 
the  whole  range  of  surgery.  The  book  supplies  a 
very  manifest  want  and  should  meet  with  suc- 
cess.— New  York  Medical  Journal,  May  31, 1884. 


14 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


FLINT,  AVSTIN,  M.  D., 

Prof,  of  the  Principles  and  Practice  of  Med.  and  of  Clin.  Med.  in  Bellev  e  Hospital  Medical  College,  N.  Y. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  of  Medicine.  AVith  an  Appendix  on  the  Researches 
of  Koch,  and  their  bearing  on  the  Etiology,  Pathology,  Diagnosis  and  Treatment  of 
Phthisis.  Fifth  edition,  revised  and  largely  rewritten  In  one  large  and  closely-printed 
octavo  volume  of  1160  pages.     Cloth,  |5.50;  leather,  $6.50;  half  Russia,  $7. 

Koch's  discovery  of  the  bacillus  of  tubercle  gives  promise  of  being  the  greatest 
boon  ever  conferred  by  science  on  humanity,  surpassing  even  vaccination  in  its  benefits  to 
mankind.  In  the  appendix  to  his  work.  Professor  Flint  deals  with  the  subject  from  a 
practical  standpoint,  discussing  its  bearings  on  the  etiology,  pathology,  diagnosis,  prog- 
nosis and  treatment  of  pulmonary  phthisis.  Thus  enlarged  and  completed,  this  standard 
work  will  be  more  than  ever  a  necessity  to  the  physician  who  duly  appreciates  the  re- 
sponsibility of  his  calling. 


A  well-known  writer  and  lecturer  on  medicine 
recently  expressed  an  opinion,  in  the  highest  de- 
gree complimentary  of  the  admirable  treatise  of 
Dr.  Flint,  and  in  eulogizing  it,  he  described  it  ac- 
curately as  "readable  and  reliable."  No  text-book 
is  more  calculated  to  enchain  the  interest  of  the 
student,  and  none  better  classifies  tiie  multitudi- 
nous subjects  included  in  it.  It  has  already  so  far 
won  its  way  in  England,  that  no  inconsiderable 
number  of  men  use  it  alone  in  the  study  of  pure 
medicine;  and  we  can  say  of  it  that  it  is  in  every 
•way  adapted  to  serve,  not  only  as  a  complete  guide, 


This  work  is  so  widely  known  and  accepted  as 
the  best  American  text-book  of  the  practice  of 
medicine  that  it  would  seem  hardly  worth  while  to 
give  this,  the  fifth  edition,  anything  more  than  a 
passing  notice.  But  even  the  most  cursory  exami- 
nation shows  that  it  is,  practically,  much  more 
than  a  revised  edition;  it  is,  in  fact,  rather  anew 
work  throughout.  This  treatise  will  undoubtedly 
continue  to  hold  the  first  place  in  the  estimation 
of  American  physicians  and  students.  No  one  of 
our  medical  writers  approaches  Professor  Flint  in 
clearness  of  diction,  breadth  of  view,  and,  what  we 


but  al.so  as  an  ample  instructor  in  the  science  and  i  regard  of  transcendent  importance,  rational  esti 


practice  of  medicine.  The  style  of  Dr.  Flint  is 
always  polished  and  engaging.  The  work  abounds 
in  perspicuous  explanation,  and  is  a  most  valuable 
text-book  of  medicine. — London  Medical  News. 


mate  of  the  value  of  remedial  agents.  It  is  thor- 
oughly practical,  therefore  pre-eminently  the  book 
for  American  readers. — St.  Louis  Clin.  Rec,  Mar.  '81. 


SABTSHOBNB,  SENJRY,  M.  !>.,  LL.  J>,, 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.  A  Handbook 
for  Students  and  Practitioners.  Fifth  edition,  thoroughly  revised  and  rewritten.  In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.     Cloth,  $2.75 ;  half  bound,  |3.00. 

Within  the  compass  of  600  pages  it  treats  of  the  |  this  one;  and  probably  not  one  writer  in  our  day 
history  of  medicine,  general  pathology,  general  '  ^"-^  "  i^o^+o,.  „T,^.^rt.,v,,tTT  tvior,  n,-  pr<.vfcV,r»-r,o  fr..- 
symptomatology, and  physical  diagnosis  (including 
laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  it  is  one  of  the  best 
of  its  kind  that  we  have  seen. — Glasgow  Medical 
Journal,  Nov.  1882. 

An  indispensable  book.    No  work  ever  exhibited 
a  better  average  of  actual  practical  treatment  than 


had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials, as  the  name  suggests,  are  not  intended  to 
supersede  the  text-books  of  Flint  and  Bartholow, 
but  they  are  the  most  valuable  in  affording  the 
means  to  see  at  a  glance  the  whole  literature  of  anj' 
disease,  and  the  most  valuable  treatment. — Chicago 
Medical  Journal  and  Examiner,  April,  1882. 


BJRISTOWJE,  JOMW  STJEM,  M,  D.,  F.  M.  C.  F,, 

Physician  and  Joint  Lecturer  on  Medicine  at  St.  Thomas^  Hospital,  London. 

A  Treatise  on  the  Practice  of  Medicine.  Second  American  edition,  revised 
by  the  Author.  Edited,  with  additions,  by  James  H.  Hutchinson,  M.D.,  physician  to  the 
Pennsylvania  Hospital.  In  one  handsome  octavo  volume  of  1085  pages,  with  illustrations. 
Cloth,  $5.00  ;  leather,  $6.00 ;  very  handsome  half  Russia,  raised  bands,  $6.50. 

The  reader  will  find  every  conceivable  subject  are  appropriate  and  practical,  and  greatly  add  to 

connected  with  the  practice  of  medicine  ably  pre-  its  usefulness  to  American  readers.— £ii/foJo  Med- 

sented,  in  a  style  at  once  clear,  interesting  and  ical  and  Surgical  Journal,  March,  1880. 
concise.    The  additions  made  by  Dr.  Hutchinson 


WATSOW,  SIB  TSOMAS,  M.  D., 

Late  Physician  in  Ordinary  to  the  Queen. 

Lectures  on  the  Principles  and  Practice  of  Physic.  A  new  American 
from  the  fifth  English  edition.  Edited,  with  additions,  and  190  illustrations,  by  Henry 
Hartshorne,  A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 
In  two  large  octavo  volumes  of  1840  pages.     Cloth,  $9.00  ;  leather,  $11.00. 


LECTURES  ON  THE  STUDY  OF  FEVER.  By 
A.  Hudson,  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.    Cloth,  $2.50. 

STOKES'  LECTURES  ON  FEVER.  Edited  by 
John  William  Moore,  M.  D.,  F.  K.  Q.  C.  P.  In 
one  octavo  volume  of  280  pages.    Cloth,  $2.00. 


A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.    In  one  8vo.  vol.  of  354  pp.    Cloth,  $2.25. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  large  and  hand- 
some octavo  volumes  of  1468  pp.    Cloth,  $7.00. 


A  CENTURY  OF  AWDERICAN  MEDICINE,  1776—1876.    By    Drs.  E.  H.  Claeke,  H.  J. 
BiGELOW,  S.  D.  GrKOSS,  T.  G.  Thomas,  and  J.  S.  Billings.    In  one  12mo.  volume  of  370  pages.    Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications — Systems  of  Med.  15 

For  Sale  by  Subscription  Only. 


A  System  of  Practical  Medicine. 

BY  AMERICAN  AUTHORS. 
Edited  by  WILLIAM   PEPPER,  M.  D.,  LL.  D., 

PROVOST  AND  PROFESSOR  OF  THE  THEORY  AND   PRACTICE  OF   MEDICINE  AND  OP 
CLINICAL  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA, 

Assisted  by  Louis  Starr,  M.  D.,  Clinical  Professor  of  the  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania. 

In  five  imperial  octavo  volumes,  containing  about  1100  fages  each,  with  illustrations.     Price  per 

volume,  cloth,  $5;  leather,  $6  ;  half  Russia,  raised  hands  and  open  hack,  $7.     Volumes 

I,  II.,  III.  and  IV.,  containing  4315  pages  and  140  illustrations,  are  now  ready. 

Volume   V.  will  be  ready  in  June. 


In  this  great  work  American  medicine  will  be  for  the  first  time  represented  by  its 
worthiest  teachers,  and  presented  in  the  full  development  of  the  practical  utility  which  is  its 
preeminent  characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
]S'orth  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  for  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  each  author  has  had 
assigned  to  him  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
will  be  accepted  as  the  latest  expression  of  scientific  anjd  practical  knowledge.  The 
practitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  and  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  found  most 
efiicient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5500  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary 
octavos.     Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

As  the  complete  material  for  the  work  is  in  the  hands  of  the  editor,  the  profession  may 
confidently  await  the  appearance  of  the  remaining  volumes  upon  the  dates  above  speci- 
fied. A  detailed  prospectus  of  the  work  will  be  sent  to  any  address  on  application  to  the 
publishers. 

American  Authors"  is  a  monument  to  American 
medicine. — Journal  of  American  Medical  Associa- 
tion, December  5, 1885. 

We  consider  it  one  of  the  grandest  works  on 
Practical  Medicine  in  the  English  language.  It  is 
a  work  of  which  the  profession  of  this  country  can 
feel  proud.  Written  exclusively  by  American 
physicians  who  are  acquainted  with  all  the  varie- 
ties of  climate  in  the  United  State.«,  the  character 
of  the  soil,  the  manners  and  customs  of  the  peo- 
ple, etc.,  it  is  peculiarly  adapted  to  the  wants 
of   American  practitioners  of    medicine,    and   it 


This  magnificent  work  has  filled  us  with  feel- 
ings of  warm  admiration.  It  is  adorned  with  a 
galaxy  of  famous  names,  many  of  them  familiar 
to  the  European  student  as  representative  of  the 
best  work  done  in  scientific  medicine  in  the 
Western  Continent,  and  the  articles  are  therefore 
to  be  regarded  as  coming  from  the  highest  au- 
thorities on  the  particular  subjects  of  which  they 
treat.  We  would  offer  our  congratulations  on  the 
excellence  of  the  System  of  Medicine,  and  in  ex- 
pressing our  high  opinion  of  the  work  we  have 
only  to  add  our  hearty  wish  that  it  may  he  read  as 

much  in  this  country  as  it  deserves. — Edinburq/i  |  .seems  to  us  that  every  one  of  them  would  desire 
M&lical. Journal,  February,  188i;.  |  to  have  it.     It  has  been  truly  called  a  "Complete 

The  third  volume  of  this  great  work,  which  at-  i  Library  of  Practical  Medicine,"  and  the  general 
tained  a  merited  popularity  immediately  on  the  I  practitioner  will  require  little  else  in  his  round 
issue  of  the  first  volume,  is  in  no  way  inferior  to  of  professional  duties.— Otncinnaii  Medical  News, 
its  predecessors.    This  "System  of  JMedicine  by  |  March,  188C.  . 


REYNOLDS,  J.  RUSSELL,  M,  Z>., 

ProfMHor  of  the  Principles  and  Practice  of  Medicine  in  Unioersity  College,  London. 

A  System  of  Medicine.  Witli  notes  and  a^lditions  by  Henry  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  .3056  double-ooliimned  pages,  with  317  illustra- 
tions, i'rice  per  volume,  cloth,  %oM) ;  sheep.  $0.00;  very  handsome  half  Eussia,  raised  bandp, 
$6.50.     Per  set,  cloth,  $15;  leather,  $18;  half  Russia,  $19.50.    Sold  only  by  subscription. 


16  Lea  Brothers  &  Co.'s  Publications — Clinical  Med.,  etc. 

FOTSBBGILL,  J,  M.,  M.  D.,  Edin.,  M,  jB.  C.  P.,  Lond,, 

Physician  to  the  City  of  London  Hospital  for  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics.  New  edition.     In  one  octavo  vohime.    Shortly. 

From  the  Preface  to  the  Previous  Edition. 

This  work  is  not  an  imperfect  Practice  of  Physic,  but  an  attempt  of  original  character 
to  explain  the  rationale  of  our  therapeutic  measures.  First  tlie  physiology  of  each  sub- 
ject is  given,  then  the  pathology  is  reviewed,  so  far  as  they  bear  on  the  treatment ;  next 
the  action  of  remedies  is  examined ;  after  which  their  practical  application  in  concrete 
prescriptions  is  furnished.  It  is  designed  to  furnish  to  the  practitioner  reasons  for  the 
faith  which  is  in  him ;  and  is  a  work  on  medical  tactics  for  the  bedside  rather  than  the 
examination  table. 


STILLB,  ALFRED,  M.  Z>.,  LL.  D., 

Professor  Emeritus  of  the  Theory  and  Practice  of  Med.  and  of  Clinical  Med.  in  the  Univ.  of  Penna. 
Cholera :   Its  Origin,  History,  Causation,  Symptoms,  Lesions,  Prevention  and  Treat- 
ment. In  one  handsome  12mo.  volume  of  163  pages,  with  a  chart.  Cloth,  $1.25.  Just  ready. 

for  a  rational  system.  Altogether,  the  monograph 
is  one  that  will  have  an  excellent  influence  on  the 
professional  mind. — Medical  and  Surgical  Reporter. 


This  timely  little  work  is  full  of  the  learning 
and  good  judgment  which  marks  all  that  comes 
from  the  pen  of  its  distinguished  author.  What 
he  has  to  say  on  treatment  is  characterized  by 
his  usual  caution  and  hi?  well-known  preference 


August  1, 1885.    q. 


FLINT,  AUSTIN,  M,  D, 

Clinical  Medicine.  A  Systematic  Treatise  on  the  Diagnosis  and  Treatment  of 
Diseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In  one  large  and  hand- 
some octavo  volume  of  799  pages.     Cloth,  $4.50 ;  leather,  $5.50 ;  half  Eussia,  $6.00. 


It  is  here  that  the  skill  and  learning  of  the  great 
clinician  are  displayed.  He  has  given  us  a  store- 
house of  medical  knowledge,  excellent  for  the  stu- 
dent, convenient  for  the  practitioner,  the  result  of 
a  long  life  of  the  most  faithful  clinical  work,  col- 
lected by  an  energy  as  vigilant  and  systematic  as 
untiring,  and  weighed  by  a  judgment  no  less  clear 
than  his  observation  is  close. — Archives  of  Medicine, 
Dec.  1879. 

To  give  an  adequate  and  useful  conspectus  of  the 
extensive  field  of  modern  clinical  medicine  is  a  task 
of  no  ordinary  difficulty;  but  to  accomplish  this  con- 


sistently with  brevity  and  clearness,  the  different 
subjects  and  their  several  parts  receiving  the 
attention  which,  relatively  to  their  importance, 
medical  opinion  claims  for  them,  is  still  more  diffi- 
cult. This  task,  we  feel  bound  to  say,  has  been 
executed  with  more  than  partial  success  by  Dr. 
Flint,  whose  name  is  already  familiar  to  students 
of  advanced  medicine  in  this  country  as  that  of 
the  author  of  two  works  of  great  merit  on  special 
subjects,  and  of  numerous  papers  exhibiting  much 
originality  and  extensive  research. — The  Dublin 
Journal,  Dec.  1879. 


By  the  Same  Author. 
Essays  on  Conservative  Medicine  and  Kindred  Topics.  In  one  very  hand- 
some royal  12mo.  volume  of  210  pages.    Cloth,  $1.38. 

FINLAYSON,  JAMFS,  M,  D,,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 
Clinical  Diagnosis.  A  Handbook  for  Students  and  Practitioners  of  Medicine. 
With  Chapters  by  Prof.  Gairdner  on  the  Physiognomy  of  Disease ;  Prof.  Stephens  on 
Diseases  of  the  Female  Organs ;  Dr.  Robertson  on  Insanity ;  Dr.  Gemmell  on  Physical 
Diagnosis ;  Dr.  Coats  on  Laryngoscopy  and  Post-Mortem  Examinations,  and  by  the  Editor 
on  Case-taking,  Family  History  and  Symptoms  of  Disorder  in  the  Various  Systems.  New 
edition.  In  one  handsome  12mo.  volume  of  600  pages,  Avith  about  100  illustrations. 
Preparing. 

BBOADBENT,  W.  S.,  M.  n,,  F.  M.  O.  F., 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary''s  Hospital. 
The  Pulse.    In  one  12mo.  volume.   Preparing.    See  Series  of  Clinical  Manuals,  page  4. 


FENWICK,  SAMUEL,  M.  D,, 

Assistant  Physician  to  the  London  Hospital. 

The  Student's  Guide  to  Medical  Diagnosis.  From  the  third  revised  and 
enlarged  English  edition.  In  one  very  handsome  royal  12mo.  volume  of  328  pages,  with 
87  illustrations  on  wood.     Cloth,  $2.25. 

TANNEB,  THOMAS  HAWEIES,  M.  D. 

A  Manual  of  Clinical  Medicine  and  Physical  Diagnosis.  Third  American 
from  the  second  London  edition.  Eevised  and  enlarged  by  Tilbury  Fox,  M.  D. 
In  one  small  12mo.  volume  of  362  pages,  with  illustrations.     Cloth,  $1.50. 

STURGES'  INTRODUCTION  TO  THE  STUDY  |  DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to  IMPORTANT  DISEASES.  By  N.  S.  Davis. 
the  Investigation  of  Disease.  In  one  handsome  M.  D.  Edited  by  Frank  H.  Davis,  M.  D.  Second 
l2mo.  volume  of  127  pages.    Cloth,  $1.25.  |      edition.    12mo.  287  pages.    Cloth,  81.75. 


Lea  Brotpiers  &  Co.'s  Publications — Hygiene,  Electr.,  Pract.        17 


mCSABDSOW,  B.  W.,  M.A.,  M,D.,  LL,  JD.,  F,It,S.,  F.S,A, 

Fellow  of  the  Royal  College  of  Physicians,  London. 
Preventive  Medicine.     In  one  octavo  volume  of  729  pages.     Cloth,  $4;  leather, 
$5 ;  very  handsome  half  Russia,  raised  bands,  $5.50. 
Dr.  Richardson  has  succeeded  in  producing  a  [  the  question  of  disease  is  comprehensive,  masterly 


work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  character,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.  He  evinces  the  happy 
faculty  of  extracting  the  pith  of  what  is  known  on 
the  subject,  and  of  presenting  it  in  a  most  simple, 
intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  the  general  public 
that  contains  such  a  complete,  reliable  and  instruc- 
tive collection  of  data  upon  the  diseases  common 
to  the  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarlj' ;  the  discussion  of 


and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable. —  The 
American  Journal  of  the  Medical  Sciences,  April,  1884. 

This  is  a  book  that  will  surely  find  a  place  on  the 
table  of  every  progressive  physician.  To  the 
medical  profession,  whose  duty  is  quite  as  much  to 
prevent  as  to  cure  disease,  the  book  will  be  a  boon. 
— Boston  Medical  and  Surgical  Journal,  Mar.  6,  1884. 

The  treatise  containsa  vast  amount  of  solid,  valu- 
able hygienic  information. — Medical  and  Surgical 
Reporter,  Feb.  23,  1884. 


BABTSOLOW,  BOBBBTS,  A,  M,,  M.  D.,  LL.  B., 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Philq,.,  etc. 
Medical  Electricity.     A  Practical  Treatise  on  the  Applications  of  Electricity 
to  Medicine  and  Surgery.     New  (third)  edition.     In  one  very  handsome  octavo  volume  of 
300  pages,  with  about  125  illustrations.     Preparing. 
A  notice  of  the  previous  edition  is  appended. 
A  most  excellent  work,  addressed  by  a  practi-  [  practice.    In  a  condensed,  practical  form,  it  pre- 


tioner  to  his  fellow-practitioners,  and  therefore 
thoroughly  practical.  The  work  now  before  us 
has  the  exceptional  merit  of  clearly  pointing  out 
where  the  benefits  to  be  derived  from  electricity 
must  come.  It  contains  all  and  everything  that 
the  practitioner  needs  in  order  to  understand  in- 
telligently the  nature  and  laws  of  the  agent  he  is 
making  use  of,  and  for  its  proper  application  in 


sents  to  the  physician  all  that  he  would  wish  to 
remember  after  perusing  a  whole  library  on  medical 
electricity,  including  the  results  of  the  latest  in- 
vestigations. It  is  the  book  for  the  practitioner, 
and  the  necessity  for  a  second  edition  proves_  that 
it  has  been  appreciated  by  the  profession.- 
cian  and  Surgeon,  Dec.  1882. 


THE  YBAB-BOOK  OF  TBBATMENT  FOB  1883. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine.    In  one  12mo.  volume  of  .320  pages,  bound  in  limp  cloth,  §1.25.     Just  ready. 

One  strong  feature  of  the  book  is  that  treatment 
conies  in  for  a  greater  share  of  attention  than 
pathology,  and  this  gives  to  it  a  practical  nature — 
because,  what  the  practitioner  wants  to  know  is 
not  a  theory  or  a  scientific  explanation,  but  what 
is  the  best  thing  for  him  to  do  in  certain  emer- 
gencies, or  how  he  can  improve  his  treatment. 
He  can  learn  by  consulting  the  Year-Book  of  Treat- 


ment what  has  been  done  all  over  the  world  by 
the  best  practitioners  in  medicine  and  surgerj',  in 
every  department  and  in  every  specialty.  As  the 
book  is  arranged  in  sections,  there  caia  be  little 
difficulty  in  finding  out  what  may  be  required; 
and  as  the  descriptions  of  the  newer  methods  of 
operation  are  very  full,  even  new  operations  can 
be  tried. — Provincial  Medical  Journal,  March  1,  '86. 


THE  YEAB-BOOK  OF  TBEATMENT  FOB  1884. 


Similar  to  that  of  1885  above. 

It  is  a  complete  account  of  the  more  important 
advances  made  in  the  treatment  of  disease.  Ex- 
treme pains  have  been  taken  to  explain  clearly  in 
the  fewest  nossible  words  the  views  of  each 
writer,  and  tlie  details  of  each  subject.  One  of 
the  principle  points  about  the  book  is  its  practical, 
yet  concise  language.  Each  editor  has  well  per- 
formed his  duty,  and  we  can  say  with  truth  that 
it  is  a  volume  well  worth  buying  for  frequent  u.se. 
—  Virginia  Medical  Monthly,  March,  188.5. 

In  a  few  moments  the  busy  practitioner  can  re- 
fresh his  mind  as  to  the  principal  advances  in 


treatment  for  a  year  past.  This  kind  of  work  is 
peculiarly  useful  at  the  present  time,  when  current 
literature  is  teeming  with  innumerable  so-called 
advances,  of  which  the  practitioner  has  not  time 
to  determine  the  value.  Here  he  has,  collected 
from  many  sources,  a  resume  of  the  theories  and 
fact.s  which  are  new,  either  entirely  or  in  part,  the 
decision  as  to  their  novelty  being  made  by  those 
who  by  wide  reading  and  long  experience  are 
fully  competent  to  render  such  a  verdict. — Ameri- 
can Journal  of  the  Medical  Sciences,  April,  1885. 


HABEBSHON,  S.  O.,  M.  L>., 

Senior  Physician  to  and  late  Led.  on  Principles  and  Practice  of  Med.  at  Guy\s  Hospital,  London. 

On  the  Diseases  of  the  Abdomen ;  Comprising  those  of  the  Stomach,  and 
other  {larts  of  the  A 1  imentary  Canal,  di^soi^hligus,  Csecuni,  Intestines  and  Peritoneum.  Second 
American  from  third  enlarged  and  revised  English  edition.  In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.     Cloth,  1)3.50. 


SCHBEIBEB,  BB.  JOSEPH. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  VVAi/rKH  Mkndelson,  M.  D.,  of  New  York.  In  one  handsome 
octavo  volume  of  about  300  pages,  with  about  125  fine  engravings.    Preparing. 


TODD'S  CLINICAL  LECTURES  ON   CERTAIN  I  HOLLAND'S  MEDICAL  NOTES  AND  RBFLEC- 

AC'UTE  DI8EAHE.S.    In  one  octavo  volume  of       TIONS.    1  vol.  8vo.,  pp.  493.    Cloth,  1.3.50. 
VM  pages.        Cloth,  tL50.  j 


18 


Lea  Brothers  &  Co.'s  Publications — Throat,  Liimgs,  Heart. 


FLINT,  AUSTIN,  M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Medical  College,  N.  7. 

A.  Manual  of  Auscultation  and  Percussion;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fourth  edition.  In  one 
handsome  royal  12mo.  volume  of  278  pages,  with  14  illustrations.    Cloth,  |1.75.  Just  ready. 

The  student  needs  a  first-class  text-book  in 
which  the  subject  is  fully  explained  for  him  to 
study.  Dr.  Flint's  work  is  lust  such  a  book.  It 
contains  the  substance  of  the  lessons  which  the 
author  has  for  many  years  given  in  connection 
with    practical    instruction    m  auscultation    and 


percussion  to  private  classes,  composed  of  medical 
students  and  practitioners.  The  fact  that  within 
a  little  more  than  two  years  a  large  edition  of  this 
manual  has  been  exhausted,  is  proof  of  the  favor 
with  which  it  has  been  regarded  by  the  medical 
profession. —  Cincianati  Medical  News,  Feb.  1886. 


B  7  THE  SAME  A  UTHOR. 

Physical  Exploration  of  the  Lungs  by  Means  of  Auscultation  and 
Percussion.  Three  lectures  delivered  before  the  Philadelphia  County  Medical  Society, 
1882-83.     In  one  handsome  small  12mo.  volume  of  83  pages.     Cloth,  $1.00. 


A  Practical  Treatise  on  the  Physical  Exploration  of  the  Chest  and 
the  Diagnosis  of  Diseases  Affecting  the  Respiratory  Organs.  Second  and 
revised  edition.     In  one  handsome  octavo  volume  of  591  pages.     Cloth,  $4.50. 

Phthisis:  Its  Morbid  Anatomy,  Etiology,  Symptomatic  Events  and 
Complications,  Fatality  and  Prognosis,  Treatment  and  Physical  Diag- 
nosis ;  In  a  series  of  Clinical  Studies.  In  one  handsome  octavo  volume  of  442  pages. 
Cloth,  $3.50.  

A  Practical  Treatise  on  the  Diagnosis,  Pathology  and  Treatment  of 
Diseases  of  the  Heart.  Second  revised  and  enlarged  edition.  In  one  octavo  volume 
of  550  pages,  with  a  plate.     Cloth,  $4. 

COHBN,  J.  SOUS,  M.  !>,, 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  CEsophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustrations.  In 
one  very  handsome  octavo  volume.     Preparing. 


SEIIBJR,  CAUL,  M.  D., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  Second  edition.  In  one  handsome  royal  12mo.  volume 
of  294  pages,  with  77  illustrations.     Cloth,  $1.75. 


It  is  one  of  the  best  of  the  practical  text-books 
on  this  subject  with  which  we  are  acquainted.  The 
present  edition  has  been  increased  in  size,  but  its 
eminently  practical  character  has  been  main- 
tained. Many  new  illustrations  have  also  been 
introduced,  a  case-record  sheet  has  been  added, 


and  there  are  a  valuable  bibliography  and  a  good 
index  of  the  whole.  For  any  one  who  wishes  to 
make  himself  familiar  with  the  practical  manage- 
ment of  cases  of  throat  and  nose  disease,  the  book 
will  be  found  of  great  value. — New  7ork  Medical 
Journal,  June  9, 1883. 


BMOWNE,  LUNNOX,  F,  B,  C.  S,,  Fdin., 

Senior  Surgeon  to  the  Central  London  Throat  and  Ear  Hospital,  etc. 
The  Throat  and  its  Diseases.     Second  American  from  the  second  English  edi- 
tion, thoroughly  revised.     With  100  typical  illustrations  in  colors  and  50  wood  engravings, 
designed  and  executed  by  the  Author.     In  one  very  handsome  imperial  octavo  volume  of 
about  350  pages.     Preparing. 

GROSS,  S.  n.,  3I.I).,  LL.n.,  D.C.L.  Oxon,,  LL.D.  Cantab. 

A  Practical  Treatise  on  Foreign  Bodies  in  the  Air-passages.    In  one 
octavo  volume  of  452  pages,  with  59  illustrations.     Cloth,  $2.75. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  $3.50. 

8LADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  pp.  158.    Cloth,  11.25. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.   In  1  vol.  8vo.,  416  pp.    Cloth,  $3.00. 

PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.    Cloth,  $2.00. 


CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNESS.    In  one  hand- 

jsome  octavo  volume  of  302  pp.    Cloth,  $2.75. 

SIfllTH  ON  CONSUMPTION;  its  Early  and  Reme- 
diable Stages.    1  vol.  8vo.,  pp.  253.    Cloth,  $2.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.    Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.  In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.50. 

JONES'  CLINICAL  OBSERVATIONS  ON  FUNC- 
TIONAL NERVOUS  DISORDERS.  Second  Am- 
erican edition.  In  one  handsome  octavo  volume 
of  340  pages.     Cloth,  $3.25. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Condie, 
M.  D.    1  vol.  Svo.,  pp.  603.    Cloth,  $2.50. 


Lea  Brothers  &  Co.'s  Publications — Nerv.  and  Ment.  Dis.,  etc.     19 


MOSS,  JAMBS,  M.D.y  F.B,aP.,  LJL,I),, 

Senior  Assista^it  Physician  to  the  Manchester  Royal  Infirmary. 

A  Handbook  on  Diseases  of  the  Wervous    System 

volume  of  725  pages,  with  184  illustrations.     Cloth,  |4.50 ;  leather, 

Dr.  Ross'  reputation  as  a  neurologist  is  so  well 
established  that  anything  we  can  say  will  scarcely 
add  to  it.  This  work  is  a  condensation  of  his  large 
treatise,  intended  for  the  use  of  students  and  for 
the  "busy  practitioner."  As  coming  from  Dr. 
Ross'  pen  the  work  can  scarcely  be  less  than  au- 
thoritative. It  is  besides,  clear,  succinct  and  read- 


In  one  octavo 
.50.  Just  ready. 
able.  The  de.gcriptions  are  always  graphic — some- 
times almost  photographic.  The  treatment  is 
always  as  definite  as  circumstances  will  permit. 
The  work  is  altogether  good— too  good  we  fear  for 
the- success  of  his  larger  work.— 2%e  Bristol  Med- 
ico-Chirurgical  Journal,  March,  1886. 


MITCHELL,  S.  WEIM,  M.  J>., 

Physician  to  Orthopaedic  Hospital  and  the  Infirmary  for  Diseases  of  the  Nervous  System,  Phila.,  etc. 

Lectures  on  Diseases  of  the  Nervous  System;  Especially  in  Women. 
Second  edition.     In  one  12mo.  volume  of  288  pages.     Cloth,  $1.75. 

No  work  in  our  language  develops  or  displays 
more  features  of  that  many-sided  affection,  liys- 
teria,  or  gives  clearer  directions  for  its  differen- 


tiation, or  sounder  suggestions  relative  to  its 
general  management  and  treatment.  The  book 
is  particularly  valuable  in  that  it  represents  in 
the  main  the  author's  own  clinical  studies,  which 
have  been  so  extensive  and  fruitful  as  to  give  his 


teacliings  the  stamp  of  authority  all  over  the 
realm  of  medicine.  The  work,  although  written 
by  a  specialist,  has  no  exclusive  character,  and 
the  general  practitioner  above  all  others  will  find 
its  perusal  profitable,  since  it  deals  with  diseases 
which  he  frequently  encounters  and  must  essay 
to  treat. — American  Practitioner,  August,  1885. 


HAMILTON,  ALLAW  McLAWE,  M.  D., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackvoelVs  Island,  N.  Y. 
Nervous  Diseases ;  Their  Description  and  Treatment.     Second  edition,  thoroughly 
revised  and  rewritten.    In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 

characterized  tliis  book  as  the  best  of  its  kind  in 


When  the  first  edition  of  this  good  book  appeared 
we  gave  it  our  emphatic  endorsement,  and  the 
present  edition  enhances  our  appreciation  of  the 
book  and  its  author  as  a  safe  guide  to  students  of 
clinical  neurology.  One  of  the  best  and  most 
critical  of  English  neurological  journals,  Brain,  has 


any  language,  which  is  a  handsome  endorsement 
from  an  exalted  source.  The  improvements  in  the 
new  edition,  and  the  additions  to  it,  will  justify  its 
purchase  even  by  those  who  possess  the  old. — 
Alienist  and  Neurologist,  April,  1882. 


TTJKE,  DAJVIEL  HACK,  M.  D., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the.  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  New  edition. 
Thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  467  pages,  with 
two  colored  plates.     Cloth,  $3.00. 


It  is  impossible  to  peruse  these  interesting  chap- 
ters without  being  convinced  of  the  author's  per- 
fect sincerity,  impartiality,  and  thorough  mental 
grasp.  Dr.  Tuke  has  exhibited  the  requisite 
amount  of  scientific  address  on  all  occasions,  and 
the  more  intricate  the  phenomena  the  more  firmly 
has   he  adhered  to  a  physiological  and  rational 


method  of  interpretation.  Guided  by  an  enlight- 
ened deduction,  the  author  has  reclaimed  for 
science  a  most  interesting  domain  in  psychology, 
previously  abandoned  to  charlatans  and  empirics. 
This  book,  well  conceived  and  well  written,  must 
commend  itself  to  every  thoughtful  understand- 
ing.—iWif  York  Medical  Journal,  September  6, 1884. 


CLOVSTON,  THOMAS  S,,  M.  H.,  F,  M,  C.  JP.,  L.  M.  C,  S,, 

Lecturer  on  Mental  Diseases  in  the  University  of  Ediiihurgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  volume  of  541 
pages,  with  eight  lithographic  plates,  four  of  wliich  are  beautifully  colored.     Cloth,  $4. 

The  practitioner  as  well  as  the  student  will  ac- 
cept the  plain,  practical  teaching  of  the  author  as  a 
forward  step  in  the  literature  of  insanity.     It  is 


the  general  practitioner  in  guiding  him  to  a  diag- 
nosis and  indicating  the  treatment,  especially  in 
many  obscure  and  doubtful  cases  of  mental  dis- 
ease. To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  make  it  a  desirable  addition  to  every  library. 
— American  Psychological  Journal,  July,  188-1. 


refreshing  to  find  a  physician  of  fir.  Clouston's 
experience  and  high  reputation  giving  the  bed- 
side note."*  upon  w/iich  iiis  experience  has  been 
founded  and  his  mature  judgment  estalilished. 
Such  clinical  observations  cannot  but  be  useful  to 

8^"Dr.  J'V)lsom's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
108  pages.     Cloth,  $1.50. 

SAVAGE,  GEORGE  H.,  M.  D., 

Lecturer  on  Mental  Diseases  at  Gu»/'«  Hospital,  London. 

Insanity  and   Allied  Neuroses,  Practical  and  Clinical.    In  one  12mo.  vol. 
of  551  i)ag(;H,  with  18  illus.     Ciotli,  $2.00.     See  Serieif  of  Clinical  Manuals,  page  4. 

PLAYEATlt,  W,  S.,  M.  llX,F~Kc.  JP., 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.    In 

one  liandHornc  Hmall  12mo.  vobirno  of  97  pagc-H.     (Jiotli,  $1.00. 

Blandford  on  Insanity  and  its  Treatment:   Lectures  on  the  Treatment, 

Medical  and  Lugiil,  of  hiHane  I'atieiitH.     In  one  very  handHonie  octavo  volume. 


20 


Lea  Brothers  &  Co.'s  Publications — Siirg-ery. 


ASHMUjRST,  JOSW,  Jr.,  M.  !>., 

Professor  of  Clinical  Surgery,  Univ.  of  Penna.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia, 

The  Principles  and  Practice  of  Surgery.  New  (fourth)  edition,  enlarged 
and  revised.  In  one  large  and  handsome  octavo  volume  of  1114  pages,  with  597  illustra- 
tions.    Cloth,  $6  ;  leather,  $7  ;  half  Eussia,  $7.50.     Jus^t  ready. 


As  with  Erichsen  so  with  Aslihurst,  its  position 
in  professional  favor  is  established,  and  one  has 
now  but  to  notice  the  changes,  if  any,  in  theory 
and  practice,  that  are  apparent  in  the  present 
as  compared  with  the  preceding  edition,  published 
three  years  ago.  The  worlv  has  been  brought  well 
up  to  date,  and  is  larger  and  better  illustrated  than 
before,  and  its  author  may  rest  assured  that  it  will 
certainly  have  a  "  continuance  of  tlie  favor  vcith 
which  it  has  heretofore  been  received."—  The 
American  Journal  of  the  Medical  Sciences,  Jan.  1886. 


Every  advance  in  surgery  worth  notice,  chroni- 
cled in  recent  literature,  has  been  suitably  recog- 
nized and  noted  in  its  proper  place.  Suffice  it  to 
say,  we  regard  Ashhurst's  Surgery,  as  now  pre- 
sented in  the  fourth  edition,  as  the  best  single 
volume  on  surgery  published  in  the  English  lan- 
guage, valuable  alilve  to  the  student  and  the  prac- 
titioner, to  the  one  as  a  text-book,  to  the  other  as 
a  manual  of  practical  surgery.  With  pleasure  we 
give  this  volume  our  endorsement  in  full. — New 
Orleans  Medical  and  Surgical  Journal,  .Jan.,  1886. 


GROSS,  S.  JO.,  M.  n.,  LL.  I).,  D.  C.  L.   Oxon.,  LL.  D, 
Cantab., 

Eme7-itus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System  of  Surgery:    Pathological,   Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.     In  two  large  and  beautifully- 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  $15;  half  Russia,  raised  bands,  $16. 
Dr.  Gross'  Si/stem  of  Surgery  has  long  been  the        His  System  of  Surgery,  which,  since  its  first  edi- 
tion in  1859,  has  been  a  standard  work  in  this 
country  as  well  as  in  America,  in  "the  whole 
domain  of  surgery,"  tells  how  earnest  and  labori- 
ous and  wise  a  surgeon  he  was,  how  thoroughly 
he  appreciated  the  work  done  by  men  in  other 
countries,  and  how  much  he  contributed  to  pro- 
mote the  science  and  practice  of  surgery  in  his 
own.    There  has  been  no  man  to  whom  America 
IS  so  much  indebted  in  this  respect  as  the  Nestor 
of  surgery. — British  Medical  Journal,  May  10, 1884. 


standard  work  on  that  subject  for  students  and 
practitioners. — London  Lancet,  May  10, 1884. 

The  work  as  a  whole  needs  no  commendation. 
Many  years  ago  it  earned  for  itself  the  enviable 
reputation  of  the  leading  American  work  on  sur- 
gery, and  it  is  still  capable  of  maintaining  that 
standard.  A  considerable  amount  of  new  material 
has  been  introduced,  and  altogether  the  distin- 

fuished  author  has  reason  to  be  satisfied  that  he 
as  placed  the  work  fully  abreast  of  the  state  of 
our  knowledge.— ikfecl  Record,  Nov.  18, 1882. 


GOVLD,  A.  JPBABCB,  M.  S.,  M,  B.,  F.  B.  C.  S., 

Assistant  Surgeon  to  Middlesex  Hospital. 

Elements  of  Surgical  Diagnosis.    In  one  pocket-size  12mo.  volume  of  589 
pages.     Cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  4. 

This  book  will  be  found  to  be  a  most  useful  This  is  a  capital  little  book,  written  by  a  prac- 

guide    for   the    hard-worked    practitioner.      Mr.  tical  man  on  a  very  practical  subject.    The  topics 

Gould's  style  is  eminently  clear  and  precise,  and  are  very  systematically  and  succinctly  arranged, 

we  can  cordially  recommend  the  manual  as  being  are  tersely  presented,  and  the  points  of  diagnosis 

the  outcome  of  the  efforts  of  an  honest  and  thor-  very  intelligently  discussed.    It  will  be  found  to 

ouglily  practical  surgeon. —  The  Medical  Neivs,  Jan.  be  of  the  greatest  amount  of  help  both  to  teacher 

24, 1885.  and  atndezxt.— Medical  Record,  Feb.  28, 1885. 


GIBWEY,  V.  JP.,  M.  JD., 

Surgeon  to  the  Orthopcedic  Hospital,  New  York,  etc. 
Orthopaedic  Surgery.    For  the  use  of  Practitioners  and  Students.    In  one  hand- 
some octavo  volume,  profusely  illustrated.     Preparing. 


JDBUITT,  BOBEBT,  M.  B.  C.  S.,  etc. 

The  Principles  and  Practice  of  Modern  Surgery.  From  the  eighth 
London  edition.     In  one  8vo.  volume  of  687  pages,  with  432  illus.     Cloth,  $4 ;  leather,  $5. 

BOBBBTS,  JOSN  B.,  A.  M.,  M.  JD., 

Lecturer  on  Anatomy  and  on  Operative  Surgery  at  the  Philadelphia  School  of  Anatomy. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students 
and  Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  about 
500  pages,  with  many  illustrations.     Preparing. 

BBLLA3IY,  EDWABD,  F.  B.  C.  S., 

Surgeon  and  Lecturer  on  Surgery  at  Charing  Cross  Hospital,  London. 
Operative  Surgery.     Shortly.     See  Students'  Series  of  Manuals,  page  4. 


SARGENT  ON  BANDAGING  and  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition, 
with  a  Chapter  on  military  surgery.  One  12mo. 
volume  of  383  pages,  with  187  cuts.    Cloth,  $1.75. 

PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.    Cloth,  $3.75. 

SKEY'S  OPERATIVE  SURGERY.  In  one  vol.  8vo. 
of  661  pages,  with  81  woodcuts.    Cloth,  ^.25. 


MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 
one  Svo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  $3.75. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth 
and  revised  American  from  the  last  Edinburgh 
edition.  In  one  large  8vo.  vol.  of  682  pages,  with 
364  illustrations.    Cloth,  $3.75. 


Lea  Brothers  &  Co.'s  Publications — Surg-ery. 


21 


EBICSSBJS',  JOSW  B,,  F.  M.  S.,  F.  R,  C.  S,, 

Professor  of  Surgery  in  University  College,  London,  etc. 

The  Science  and  Art  of  Surgery ;  Being  a  Treatise  on  Surgical  Injuries,  Dis- 
eases and  Operations.  From  the  eighth  and  enlarged  English  edition.  In  two  large  and 
beautiful  octavo  volumes  of  2316  pages,  illustrated  with  984  engravings  on  wood. 
Cloth,  |9 ;  leather,  raised  bands,  $11 ;  half  Eussia,  raised  bands,  $12. 


In  noticing  the  eighth  edition  of  this  well- 
known  work,  it  would  appear  superfluous  to  say 
more  than  that  it  has,  like  its  predecessors,  been 
brought  fully  up  to  the  times,  and  is  in  conse- 
quence one  of  the  best  treatises  upon  surgery  that 
has  ever  been  penned  by  one  man.  We  have  al- 
ways regarded  "The  Science  and  Art  of  Surgery" 
as  one  of  the  best  surgical  text-books  in  the 
English  language,  and  this  eighth  edition  only 
confirms  our  previous  opinion.  We  take  great 
pleasure  in  cordially  commending  it  to  our  read- 
ers.—TAeJfedicai  News,  April  11, 1885. 

After   being   before   the   profession   for  thirty 


years  and  maintaining  during  that  period  a  re- 
putation as  a  leading  work  on  surgery,  there  is  not 
much  to  be  said  in  the  way  of  comment  or  criti- 
cism. That  it  still  holds  its  own  goes  without  say- 
ing. The  author  infuses  into  it  his  large  experi- 
ence and  ripe  judgment.  Wedded  to  no  school, 
committed  to  no  theory,  biassed  by  no  hobby,  he 
imparts  an  honest  personality  in  his  observations, 
and  his  teachings  are  the  rulings  of  an  impartial 
judge.  Such  men  are  always  safe  guides,  and  their 
works  stand  the  tests  of  time  and  experience. 
Such  an  author  is  Erichsen,  and  such  a  work  is  his 
Surgery. — Medical  Record,  Feb.  21, 1885. 


BBTAWT,  TMOMAS,  F,  M,  a  S., 

Surgeon  and  Lecturer  on  Surgery  at  Gruy^s  Hospital,  London. 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.     In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.     Cloth,  $6.50 ;  leather,  $7.50 ;  half  Kussia,  $8.00. 

The  treatise  takes  in  the  whole  field  of  surgery, 
that  of  the  eye,  the  ear,  the  female  organs,  ortho- 
psedics,  venereal  diseases,  and  military  surgery, 
as  well  as  more  common  and  general  topics.  All 
of    these    are    treated  with    clearness   and  with 


sufficient  fulness  to  suit  all  practical  purposes. 
The  illustrations  are  numerous  and  well  printed. 
We  do  not  doubt  that  this  new  edition  will  con- 
tinue to  maintain  the  popularity  of  this  standard 
work. — Medical  and  Surgical  Reporter,  Feb.  14,  '85. 


This  most  magnificent  work  upon  surgery  has 
reached  a  fourth  edition  in  this  country,  showing 
the  high  appreciation  in  which  it  is  held  by  the 
American  profession.  It  comes  fresh  from  the 
pen  of  the  author.  That  it  is  the  very  best  work 
on  surgery  for  medical  students  we  think 
there  can  be  no  doubt.  The  author  seems  to  have 
understood  just  what  a  student  needs,  and  has 
prepared  the  work  accordingly. —  Cincinnati  Medical 
Neivs,  January,  1885. 


By  the  same  Author. 
Diseases  of  the  Breast.   In  one  12mo.  volume.   Preparing.   See  Seriesof  Clinical 
Manuals,  page  4. 

TMFVES,  FRFDFMICK,  F.  JR.  C,  S,, 

Hunterian  Professor  at  the  Royal  College  of  Surgeons  of  England. 

A  Manual  of  Surgei'y.  In  Treatises  by  Various  Authors.  In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.  Price  per  volume,  cloth,  $2.  See 
Students'  Series  of  Manuals,  page  4. 

These  volumes  aflbrd  in  a  compact  and  portable  form  a  complete  view  of  the  clinical 
aspects  of  modern  surgery  as  understood  and  practised  by  thirty-three  leading  British 
surgeons. 

BVTLIN,  SFJVMT  T.,  f',  M.  C.  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 
Diseases    of   the   Tongue.      In  one  12mo.  volume  of  456  pages,  with  S  colored 
Ijlates  and  3  woodcuts.     Cloth,  $3.50.     See  Series  of  Clinical  Manuals,  page  4. 
This   book,   the  latest    issue    of    the  "Clinical    been  written  by  one  whose  opportunities  have 


Manuals     for    Practitioners     and     Students     of 

Medicine,"    is    a    njodel    of    its    kind.       It    is 

specially  welcome,  all  the  more  so,  since  the  text 

is    really    illustrated    by  a  sufficient   number  of  I  our  re'aders. — The  Medical  News,  October  VI,18S5 

admirably  executed  colored  plates.  The  work  has  ' 


peculiarly  fitted  him  for  the  task,  since  he  teaches 
not  only  from  a  clinical  but  from  a  pathological 
.standpoint.     We  heartily  commend  the  book  to 


ESMARCH,  JDr.  FRIEDRICH, 

Professor  of  Surgery  at  the  University  of  Kiel,  etc. 

Early  Aid  in  Injuries  and  Accidents.  Five  Ambulance  Lectures.  Trans- 
lated by  il.  K.  11.  Pkinc'e.ss  Chrihtian.  In  one  liandsome  small  12mo.  volume  of  109 
pages,  with  24  illustrations.     Cloth,  75  cents. 

TREVES,  FREDERICK,  F,  R,  O.  8,, 

Surgeon  lo  anil  Lecturer  on  Surgery  at.  the  London  Hospital. 

Intestinal  Obstruction,  in  one  pocket-sizo  12mo.  volume  of  522  pages,  with  60 
ilhi.'-lrationH.  Limp  cloth,  bhie  odgos,  $2.00.     See  Series  of  Clinical  Manuals,  page  4, 

A  standard  work  on  a  Hubjftct  that  has  not  been  i  justice  to  thi-  author  in  a  few  paragraphs.  InttK- 
80  comprehenHively  treated  by  any  contemporary  Umri/  Otnilruction  is  a  work  tliut  will  'irove  of 
Enelinh  writer.  llH  cornpleleneKH  renderH  n  full  equnl  value  lo  tho  practition<^r,  the  student,  ttie 
review  difticult,  bIiico  every  chapter  deserves  mi-    [.atliologiHt,  the  nhyHician  and  the  operating  sur- 

—liritisk  McdicalJ  '    '       "^   


nute  attention,  and  It  Ih  imposHible  to  do  thorough  |  geoD.- 


:  Journal,  Jan.  31,  1885. 


BALL,  CHARLES  B.,  M.  C/u,  Dub,,  F,  R,  C.  S.  E., 

■Surgeon  and  Teacher  nl  Sir  I'.  Ixin'n  llonpilnl,  iMihlin. 

Diseases  of  the  Rectum  and  Anus,    in  one  12mo.  volume  of  550  pages. 

Prepnriwj.      Hce  Serioi  of  Clinical  Manuals,  ruigo  4. 


22      Lea  Brothers  &  Co.'s  Publications — Siirgery*  Frac,  Disloc. 


HOLMBS,  TIMOTHY,  M,  A., 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.  IN  TREATISES  BY 
VARIOUS  AUTHORS.  American  edition,  thoroughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcoiial  and  St.  Joseph's  Hospitals, 
Pliiladelphia,  assisted  by  a  corjas  of  thirty-three  of  the  most  eminent  American  surgeons. 
In  three  large  and  very  handsome  imperial  octavo  volumes  containing  3137  double- 
columned  pages,  with  979  illustrations  on  wood  and  13  lithographic  plates,  beautifully 
colored.  Price  per  volume,  cloth,  $6.00 ;  leather,  <'S)7.00  ;  half  Russia,  $7.50.  Per  set,  cloth, 
$18.00 ;  leather,  $21.00  ;  half  Russia,  $22.50.     Sold  only  by  subscription. 


The  authors  of  the  original  English  edition  are 
men  of  the  front  rank  in  England,  and  Dr.  Packard 
has  been  fortunate  in  securing  as  his  American 
coadjutors  such  men  as  Bartholow,  Hyde,  Hunt, 
Conner,  Stimson,  Morton,  Hodgen,  Jewell  and 
their  colleagues.  As  a  whole,  the  work  will  be 
solid  and  substantial,  and  a  valuable  addition  to 


the  library  of  any  medical  man.  It  is  more  wieldly 
and  more  useful  than  the  English  edition,  and  with 
its  companion  work — "  Re3molds'  System  of  Medi- 
cine"— will  well  represent  the  present  state  of  our 
science.  One  who  is  familiar  with  those  two  works 
will  be  fairly  well  furnished  head-wise  and  hand- 
wise.— T/ie  Medical  Kews,  Jan.  7, 1882. 


HAlIILTOJSr,  FBAJSTK  S,,  M,  D.,  LL.  D,, 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  Seventh  edition, 
thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo  volume  of  998 
pages,  with  379  illustrations.  Cloth,  $5.50:  leather,  $6.50;  very  handsome  half  Russia, 
open  back,  $7.00. 


It  is  about  twenty-five  j'ears  ago  since  the  first 
edition  of  this  great  work  appeared.  The  edition 
now  issued  is  the  seventh,  and  this  fact  alone  is 
enough  to  testify  to  the  excellence  of  it  in  all  par- 
ticulars. Books  upon  special  subjects  do  not 
usually  command  extended  sale,  but  this  one  is 
without  a  rival  in  any  language.  It  is  essentially 
a  practical  treatise,  and  it  gathers  within  its  covers 
almost  everything  valuable  that  has  been  written 
about  fractures  and  dislocations.  The  principles 
and  methods  of  treatment  are  very  fully  given. 
The  book  is  so  well  known  that  it  does  not  require 
any  lengthened  review.    We  can  only  say  that  it 


is  still  unapproaohed  as  a  treatise,  and  that  it  is  a 
proof  of  the  zeal  and  industry  and  great  ability  of 
its  distinguished  author. —  the  Duhlia  Journal  of 
Medical  Science,  Feb.  1886. 

With  its  first  appearance  in  1S59,  this  work  took 
rank  among  the  classics  in  medical  literature, 
and  has  ever  since  been  quoted  by  surgeons  the 
world  over  as  an  authority  upon  the  topics  of 
which  it  treats.  The  surgeon,  if  one  can  be  found 
who  does  not  already  know  the  work,  will  find  it 
scientific,  forcible  and  scholarly  in  text,  exhaustive 
in  detail,  and  ever  marked  by  a  spirit  of  wise  con- 
servatism.^— Louisville  Medical  News,  Jan.  10, 188-5. 


STIMSOW,  LBWIS  A,,  B,  A.,  31.  D., 

Professor  of  Pathological  Anatomy  at  the  University  of  the  City  of  New  York,  Surgeon  and  Curator 
to  Bellevue  Hospital,  Surgeon  to  the  Presbyterian  Hospital,  New  York,  etc. 

A  Manual  of  Operative  Surgery.     Kew  (second)  edition.    In  one  very  hand- 
some royal  12mo.  volume  of  503  pages,  with  342  illustrations.     Cloth,  $2.50.     JiMst  ready. 


Such  works  as  this  are  sure  to  find  large  popu- 
arity  when  carefully  prepared.  This  is  certainly 
the  case  with  the  volume  of  Dr.  Stimson.  It  is 
judiciously  condensed,  omitting  nothing  of  much 
importance,  and  embracing  a  complete  synopsis 


of  the  practical  parts  of  surgery.  The  text  vvill  be 
found  to  represent  in  an  entirely  satisfactory  man- 
ner the  latest  expressions  of  surgical  science  on 
its  operative  methods. — Medical  aiid  Surgical  Re- 
porter, Dec.  19,  1885. 


By  the  same  Author. 
A  Practical  Treatise  on  Fractures.    In  one  very  handsome  octavo  volume  of 
598  pages,  with  360  beautiful  illustrations.     Cloth,  $4.75  ;  leather,  $5.75. 

The  author  has  given  to  the  medical  profession 
in  this  treatise  on  fractures  what  is  likely  to  be- 
come a  standard  work  on  the  subject.  It  is  certainly 
not  surpassed  by  any  work  written  in  the  English, 
or,  for  that  matter,  any  other  language.  The  au- 
thor tells  us  in  a  short,  concise  and  comprehensive 
manner,  all  that  is  known  about  his  subject.  There 
is  nothing  scanty  or  superficial  about  it,  as  in  most 
other  treatises ;  on  the  contrary,  everything  is  thor- 


ough. The  chapters  on  repair  of  fractures  and  their 
treatment  show  him  not  only  to  be  a  profound  stu- 
dent, but  likewise  a  practical  surgeon  and  patholo- 
gist. His  mode  of  treatment  of  the  different  fract^ 
ures  is  eminently  sound  and  practical.  We  consider 
this  vrork  one  of  the  best  on  fractures  ;  and  it  will 
be  welcomed  not  only  as  a  text-book,  but  also  by 
the  surgeon  in  full  practice. — N.  O.  Medical  and 
Surgical  Journal,  March,  1883. 


MABSS,  MOWABD,  F.  B.  C.  S,, 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London. 
Diseases  of  the  Joints.   In  one  12mo.  volume.   Preparing.   See  Series  of  Clinical 
Manuals,  page  4. 

PICK,  T.  FICKBMIJSTG,  F.  M.  C,  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.     In  one  12mo.  volume  of  530  pages,  with  93 
illustrations.     Limp  cloth,  2.00.     Just  ready.     See  Series  of  Clinical  Manuals,  page  4. 

The  author  states  that  in  writing  the  book  he  1  ablJ^  The  book  bears  a  distinctly  clinical  and 
has  kept  the  fact  steadily  in  view  that  it  should  be  !  practical  stamp.  In  laying  down  rules  as  to  symp- 
essentially  clinical,  and  he  has  therefore  sought  :  toms  and  treatment,  the  author  relies  principally 
to  present  "a  concise  and  practical  treatise  of  the  ;  on  those  which  he  has  found  bj'^  practical  experi- 
eauses  of  the  various  common  fractures  and  dis-  !  ence  to  be  most  efficacious.  The  book  contains 
locations,  the  signs  by  which  they  may  be  recog-  j  an  amount  of  information  remarkable  for  one  of 
nized,  and  the  appropriate  treatment  to  be  adopted  its  size. — Boston  Medical  and  Surgical  Journal,  April 
for  their  cure."    In  this  he  has  succeeded  admir-    15,  1886. 


Lea  Brothers  &  Co.'s  Public ATiONS---Otal.,  OpMlial. 


23. 


BVRWETT,  CHAMLJES  S,,  A,  M.,  M,  !>., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic ;  President  of  the  American  Otological  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  Treatise 
for  the  use  of  Medical  Students  and  Practitioners.  New  (second)  edition.  In  one  handsome 
octavo  volume  of  580  pages,  with  107  illustrations.   Cloth,  $4.00 ;  leather,  |5.00. 

carried  out,  and  much  new  matter  added.    Dr. 


We  note  with  pleasure  the  appearance  of  a  second 
edition  of  this  vaUiable  work.  When  it  first  came 
out  it  was  accepted  by  the  profession  as  one  of 
the  standard  worljs  on  modern  aural  surgery  in 
the  English  language;  and  in  his  second  edition 
Dr.  Burnett  has  fully  maintained  his  reputation, 
for  the  book  is  replete  with  valuable  information 
and  suggestions.    The  revision  has  been  carefully 


Burnett's  work  must  be  regarded  as  a  very  valua- 
ble contribution  to  aural  surgery,  not  only  on 
account  of  its  comprehensiveness,  but  because  it 
contains  the  results  of  the  careful  personal  observa- 
tion and  experience  of  this  eminent  aural  surgeon. 
— London  Lancet,  Feb.  21,  18S5. 


POLITZBR,  AJDAM, 

Imperial- Royal  Prof,  of  Aural  Therap.  in  the  Univ.  of  Vienna. 

A  Text-Book  of  the  Ear  and  its  Diseases.  Translated,  at  the  Author's  re- 
quest, by  Jabies  Patterson  Cassells,  M.  D.,  M.  E.  C.  S.  In  one  handsome  octavo  vol- 
ume of  800  pages,  with  257  original  illustrations.     Cloth,  $5.50. 

The  work  itself  we  do  not  hesitate  to  pronounce 
the  best  upon  the  subject  of  aural  diseases  which 
has  ever  appeared,  systematic  without  being  too 
diffuse  on  obsolete  sitbjects,  and  eminently  prac- 


tical in  every  sense.  The  anatomical  descriptions 
of  each  separate  division  of  the  ear  are  admirable, 
and  profusely  illustrated  by  woodcuts.  They  are 
followed  immediately  by  the  physiology  of  the 


section,  and  this  again  by  the  pathological  physi- 
ology, an  arrangement  which  serves  to  keep  up  the 
interest  of  the  student  by  showing  the  direct  ap- 
plication of  what  has  preceded  to  the  study  of  dis- 
ease. The  whole  work  can  be  recommended  as  a 
reliable  guide  to  the  student,  and  an  efficient  aid 
to  the  practitioner  in  his  treatment. — Boston  Med- 
ical and  Surgical  Journal,  June  7, 1883. 


Senior  Ass'' t  Surgeon,  Royal  Westminster  Ophthalmic  Hosp. ;  late  Clinical  Ass' t,  Moorflelds,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  In  one  handsome 
octavo  volume  of  460  pages,  with  125  woodcuts,  27  colored  plates,  selections  from  the 
Test-types  of  Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test.  Cloth,  $4.50 ; 
leather,  $5.50. 

and  typical  illustrations  of  all  important  eye 
affections,  placed  in  juxtaposition,  so  as  to  be 
grasped  at  a  glance.  Beyond  a  doubt  it  is  the 
best  illustrated  handbook  of  ophthalmic  science 
which  has  ever  appeared.  Then,  what  is  still 
better,  these  illustrations  are  nearly  all  original. 
We  have  examined  this  entire  work  with  great 
care,  and  it  represents  the  commonly  accepted 


This  work  is  distinguished  by  the  great  num- 
ber of  colored  plates  which  appear  in  it  for  illus- 
trating various  pathological  conditions.  They  are 
very  oeautiful  in  appearance,  and  have  been 
executed  with  great  care  as  to  accuracy.  An  ex- 
amination of  the  work  shows  it  to  be  one  of  high 
standing,  one  that  will  be  regarded  as  an  authority 
among  ophthalmologists.  The  treatment  recom- 
mended is  such  as  the  author  has  learned  from 
actual  experience  to  be  the  best. — Cincinnati  Medi- 
cal I\'excs,  Dec.  1884. 

It  presents  to  the  student  concise  descriptions 


views  of  advanced  ophthalmologists.  We  can  most 

d  this  book  to  all  medical   stu- 

and    specialists.  —  Detroit 


heartily  commen 
dents,    practitioners 
Lancet,  Jan.  1885, 


JsOJRJRIS,  WM.  m,  M,  D.,  and  OLIVER,  CHAS,  A.,  M.  D. 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 

A  Text-Book  of  Ophthalmology.  In  one  octavo  volume  of  about  500  pages,, 
with  illustrations.     Preparing. 

WELLS,  J.  SOELBEBG,  F.  B.  C.  S., 

Professor  of  Ophthalmology  in  King's  College  Hospital,  London,  etc. 

A  Treatise  on  Diseases  of  the  Eye.  New  (fifth)  American  from  the  third 
London  edition.  Thoroughly  revised,  with  copious  additions,  by  L.  Webster  Fox,  M.  D. 
In  one  large  octavo  volume  of  about  850  pages,  with  about  275  illustrations  on  wood,  six 
colored  plates,  and  selections  from  the  Test-types  of  Jaeger  and  Snellen.     Preparing. 

NETTLESHIJP,  EL>WABL>,  F,  B.  C.  S., 

Ophthalmic  Surg,  and  Led.  on  Ophth.  Surg,  nt  St.  Thomas'  Hospital,  London. 

The  Student's  Guide  to  Diseases  of  the  Eye.  Second  edition.  With  a  chap- 
ter on  the  Detection  of  Color-Blindness,  by  William  Thomson,  M.  D.,  Ophthalmologist 
to  the  Jeflerson  Medical  College.  In  one  royal  12mo.  volume  of  416  pages,  with  138 
illustrations.    Cloth,  $2.00. 

BBOWNE,  EDGAB  A., 

SuKjeun  lo  the  Liverpool  Eye  and  Ear  Infirmary  and  to  the  Dispensary  for  Skin  Diseases. 
How  to  Use  the  Ophthalmoscope.     Being  Elementary  Instructions  in  Oph- 
thahnoHcopy,  arranged  for  llic  use  of  Hludeiits 
pages,  with  35  illustrations.     Cloth,  $1.00. 


its.     In  one  small  royal  12mo.  volume  of  116 


LAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 
A.NI)  EYELIDS:  Their  Immediate  and  Remote 
Kff'-ctH.    8  vo.,  404  pp.,!iiJ  illuH.    (;ioth,  8.'!.r.o. 

LAHKENCE  A.ND  MOON'S  flANDY  HOOK  OF 
OPHTHALMIC  SURGERY,  for  the  une  of  Prac- 


titionera.    Second  edition.    In  one  octavo   vol- 
ume r)f  227  page.H,  with  05  illuHt.     Cloth,  S2.7/). 
CARTER'S  PRACTICAL  TREATISE  ON  DISEAS- 
ES  OF  THE  EYE.    Edited  by  John  Guken,  M.D. 
In  one  handHome  octavo  volume. 


24         Lea  Brothers  &  Co.'-s  Publications — Urin.  Dis.^Dent. 
ROBERTS,  WILLIAM,  M,  D,, 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Renal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  the  fourth  London  edition.  In  one  hand- 
some octavo  volume  of  609  pages,  with  81  illustrations.     Cloth,  §3.50. 

The  previous  editions  of  this  book  have  made  it  The  peculiar  value  and  finish  of  the  book  are  in 
so  familiar  to  and  so  highly  esteemed  by  the  med-  a  measure  derived  fi'om  its  resolute  maintenance 
ical  public,  that  little  more  is  necessary  than  a  of  a  clinical  and  practical  character.  It  is  an  un- 
mere  announcement  of  the  appearance  of  this,  rivalled  exposition  of  everything  which  relates 
their  successor.    But  it  is  pleasant  to  be  able  to    directly  or  indirectly  to  the  diagnosis,  prognosis 


say  that,  good  as  those  were,  this  is  still  better 
In  fact,  we  think  it  may  be  said  to  be  the  best  book 
in  print  on  the  subject  of  which  it  treats. —  The 
Ainerican  Journal,  of  the  Medical  Sciences. — Jan.  1886. 
Among  the  numerous  works  on  renal  and  uri- 
nary diseases  now  in  circulation,  perhaps  Dr. 
Roberts'  has  the  best  claim  to  be  regarded  as 
"standard."  The  present  edition  shows  evidence 
of  having  been  carefully  revised,  and  appears  to 
be  well  up  to  the  times.  Dr.  Roberts'  book  is  an 
eminently  useful  and  nraotical  one,  and  we  con- 
gratulate the  author  oh  its  deserved  popularity 
with  the  profession. — Chicago  Medical  Journal  and 
Examiner,  February,  1886. 


and  treatment  of  urinary  diseases,  and  possesses 
a  completeness  not  found  elsewhere  in  our  lan- 
guage in  its  account  of  the  different  affections. — 
The  Manchester  Meiiical  Chronicle,  July,  1885. 

Tlie  work  is  practical  in  its  character,  and  is 
regarded  as  an  authority  in  the  diseases  which  it 
treats.  There  is  certainly  no  work  that  more 
fully  sets  forth  the  progress  that  has  been  made 
than  this  one  of  Dr.  Roberts,  and  that  more  fully 
meets  the  wants  of  the  physician  in  explaining 
the  best  methods  of  treatment.  We  have  no 
hesitation  in  recommending  it  to  our  subscribers. 
— Cincinnati  Medical  News,  June,  1885. 


PVRDY,    CMARLBS   W.,  A,  M.,  M.  D, 

Bright's  Disease  and  Allied  Disorders.  In  one  octavo  volume  of  350  pages, 
with  illustrations.     Shortly. 

MORRIS,  MEWRY,  M.  B.,  F.  R.  C.  S,, 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Kidney.  In  one  12mo.  volume  of  554  pages,  with 
40  woodcuts,  and  6  colored  plates.  Just  ready.  Limp  cloth,  §2.25.  See  Series  of  Glinical 
Manuals,  page  4. 

We  highly  approve  of  Mr.  Morris's  book  and  strongly  recommend  it  to  practical  surgeons. — 
Edinburgh  Medical  Journal,  April,  1886. 

LUCAS,  CLEMENT,  M.  J5.,^.  S,,  i\  R,  C.  S,, 

Senior  Assistant  Surgeon  to  Guy^s  Hospital,  London. 
Diseases    of  the    Urethra.      In   one    12mo.   volume.     Preparing.     See   Series 
of  Glinical  Manuals,  page  4. 

TSOMJPSOIf,  SIR  MENRY,  ' 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.     In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.     Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Fistulae.     From  the  third  English  edition.     In  one  octavo  volume  of  359 
pages,  with  47   cuts  and  3  plates.     Cloth,  |3.50. 

AW  AMERICAN  SYSTEM  OF  DENTISTRY, 

A  System  of  Dentistry,  in  Treatises  by  Various  Authors.  Edited  by 
Wilbur  F.  Litch,  M.  D.,  D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medicaand 
Therapeutics  in  the  Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome 
octavo  volumes  of  about  800  pages  each,  richly  illustrated.  Per  volume,  cloth,  §6  ;  leather, 
$7  ;    half  Morocco,  gilt  top,  |S.     Volume  L,  just  ready.     For  sale  by  subscription  only. 

COLEMAN,  A,,  L.  R.  C,  F.,  F,  R.  C.  S.,  Exam.  L.  D.  S., 

Senior  Dent.  Surg,  and  Led.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hasp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  STELLWAaEN,  M.  A.,  M.  D., 
D.  D.  S.,  Prof,  of  Physiology  at  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 

This  volume  presents  a  highly  creditable  ap-  I  ence.  The  book  deserves  a  place  in  the  library  of 
pearance,  and  deserves  to  rank  among  the  most  1  every  dentist. — Dental  Cosmos,  May,  1882. 
important  of  recent  contributions  to  dental  litera-  I  It  should  be  in  the  possession  of  every  prac- 
ture.  Mr.  Coleman  has  presented  his  methods  of  |  titioner  in  this  country.  The  part  devoted  to  first 
practice,  for  the  most  part,  in  a  plain  and  concise  ]  and  second  dentition  and  irregularities  in  the 
manner,  and  the  work  of  the  American  editor  has  i  permanent  teeth  is  fully  worth  the  price.  In  fact, 
been  conscientiously  performed.  He  has  evi-  '  price  should  not  be  considered  in  purchasing  such 
dently  labored  to  present  his  convictions  of  the  j  a  work.  If  the  money  put  into  some  of  our  so- 
best  modes  of  practice  for  the  instruction  of  those  !  called  standard 'test-boiDks  could  be  converted  into 
commencing  a  professional  career,  and  he  has  j  such  publications  as  this,  much  good  would  re- 
faithfull}"-  endeavored  to  teach  to  others  all  that  he  I  suit. — Southern  Dental  Journal,  May,  1882. 
has  acquired  by  his  own  observation  and  experi-  1 


BASHAM    ON    RENAL    DISEASES  :   A   Clinical    I    one  12mo.  vol.  of  304  pages,  with  21  illustrations. 
Guide  to  their  Diagnosis  and    Treatment.    In    |    Cloth,  S2.00. 


Lea  Brothers  &  Co.'s  Publications — Venereal,  Impotence. 


25 


BUMSTJEAJ),  F.  J., 

M.  D,,  LL.  JD., 

Late  Professor  of  Venereal  Diseases 
at  the  College  of  Physicians  and 
Surgeons,  Neio  York,  etc. 


and 


TAYLOR,  M.  W.f 

A.  M.,  M.  J>., 

Surgeon  to  Charity  Hospital,  New  York,  Prof,  of 
Venereal  and  Skin  Diseases  in  the  University  of 
Vermont,  Pres.  of  the  Am.  Dermatological  Ass'n. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  InclndiDg  the 
results  of  recent  investigations  upon  the  subject.  Fifth  edition,  revised  and  largely  re- 
written, by  Dr.  Taylor.  In  one  large  and  handsome  octavo  volume  of  898  pages  with 
139  illustrations,  and  thirteen  chromo-lithographic  figures.  Cloth,  $4.75  ;  leather,  $5.75  ; 
very  handsome  half  Kussia,  $6.25. 


It  is  a  splendid  record  of  honest  labor,  wide 
research,  just  comparison,  careful  scrutiny  and 
original  experience,  which  will  always  be  held  as 
a  high  credit  to  American  medical  literature.  This 
is  not  only  the  best  work  in  the  English  language 
upon  the  subjects  of  which  it  treats,  but  also  one 
which  has  no  equa.  in  other  tongues  for  its  clear, 
comprehensive  and  practical  handling  of  its 
themes. — American  Journal  of  the  Medical  Sciences, 
Jan,  1884. 

It  is  certainly  the  best  single  treatise  on  vene- 
real in  our  own,  and  probably  the  best  in  any  lan- 
guage.— Boston  Medical  and  Surgical  Journal,  April 
3, 1884. 


The  character  of  this  standard  work  is  so  weli 
known  that  it  would  be  superfluous  here  to  pass  in 
review  its  general  or  special  points  of  excellence. 
The  verdict  of  the  profession  has  been  passed;  it 
has  been  accepted  as  the  most  thorough  and  com- 
plete exposition  of  the  pathology  and  treatment  of 
venereal  diseases  in  the  language.  Admirable  as  a 
model  of  clear  description,  an  exponent  of  sound 
pathological  doctrine,  and  a  guide  for  rational  and 
successful  treatment,  it  is  an  ornament  to  the  medi- 
cal literature  of  this  country.  The  additions  made 
to  the  present  edition  are  eminently  judicious, 
from  the  standpoint  of  practical  utility. — Journal  of 
Cutaneous  and  Venereal  Diseases,  Jan.  1884. 


coMJsnij,  v., 

Professor  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lour  cine  Hospital. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  University  of  Pennsylvania,  and 
J.  WiiiLiAM  White,  M.  D.,  Lecturer  on  Venereal  Diseases  and  Demonstrator  of  Surgery 
in  the  University  of  Pennsylvania.  In  one  handsome  octavo  volume  of  461  pages,  with 
84  very  beautiful  illustrations.     Cloth,  $3.75. 

the  whole  volume  is  the  clinical  experience  of  the 
author  or  the  wide  acquaintance  of  the  translators 
with  medical  literature  more  evident.     The   anat- 


The  anatomical  and  histological  characters  of  the 
hard  and  soft  sore  are  admirably  described.  The 
multiform  cutaneous  manifestations  of  the  disease 
are  dealt  with  histologically  in  a  masterly  way,  as 
we  should  indeed  expect  them  to  be,  and  the 
accompanying  illustrations  are  executed  carefully 
and  well.  The  various  nervous  lesions  which  are 
the  recognized  outcome  of  the  syphilitic  dyscrasia 
are  treated  with  care  and  consideration.  Syphilitic 
epilepsy,  paralysis,  cerebral  syphilis  and  locomotor 
ataxia  are  subjects  full  of  interest ;  and  nowhere  in 


omy,  the  histology,  the  pathology  and  the  clinical 
features  of  syphilis  are  represented  in  this  work  in 
their  best,  most  practical  and  most  instructive 
form,  and  no  one  will  rise  from  its  perusal  without 
the  feeling  that  his  grasp  of  the  wide  and  impor- 
tant subject  on  which  it  treats  is  a  stronger  and 
surer  one. —  The  London  Practitioner,  Jan.  1882. 


ElUTCSIJV^SOJV,  JOWATSAJSr,  F,  M,  S.,  F,  M.  C.  S., 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.    In  one  12mo.  volume.   Preparing.    See  Series  of  Clinical  Manuals,  page  4. 

GMOSS,  SAMUEL  W,,  A,  31.,  M.  L>., 

Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery  in  the  Jefferson  Medical  College  of  Phila. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  Second  edition,  thoroughly  revised.  In  one  very  hand- 
some octavo  volume  of  168  pages,  with  16  illustrations.     Cloth,  $1.50. 

book  shows  that  he  has  not  neglected  to  compare 
his  own  views  with  those  of  otlier  authors.  The 
result  is  a  work  which  can  be  safely  recommended 


The  author  of  this  monograph  is  a  man  of  posi- 
tive convictions  and  vigorous  style.  This  is  justi- 
fied by  his  experience  and  by  his  study,  vvhicn  has 
gone  hand  in  hand  with  his  experience.  In  regard 
K)  the  various  organic  and  functional  disorders  of 
the  male  generative  apparatus,  he  has  had  ex- 
ceptional opportunities  for  observation,  and  his 


to  both  physicians  and  surgeons  as  a  guide  in  the 
treatment  of  the  disturbances  it  refers  to.  It  is 
the  best  treatise  on  the  suVjject  with  which  we  are 
acquainted. — The  Medical  News,  Sept.  1, 1883. 


(}ROSS,  S,  J).,  M.  JD.,  LL.  JD.,  jD.  C.  X.,  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thorouglily  revised  by  Samuel  W.  Gross,  M.  D.  In  one  octavo  volume  of  574 
pages,  witli  170  ilUistrations.     Cloth,  $4.50. 

CULLEBTEIt,  A.,  &  BUMSTEAD,  F.  J.,  M.L>.,  LL.n., 

Surgeon  to  the  HCpital  du  Midi.  Jjate  Professor  of  Venereal  Diseases  in  the  College  of  Physicians 

ami  Surgeons,  I^ew  York. 

An  Atlas  of  Venereal  Diseases.  Tmn.slateil  and  edited  by  Freeman  J.  Bum- 
STEAi),  M.  D.  In  one  imperial  4to.  volume  of  328  pages,  double-columns,  with  26  jilates, 
containing  about  150  figurcH,  beiiutifully  colored,  many  of  them  the  size  of  life.  Strongly 
boimd  in  cloth,  $17.00.    A  specimen  of  the  plates  and  text  sent  by  mail,  on  receipt  of  25  cts. 

HILI.ON  SYPHILIS  AND  LOCAL  CONTAfJIOUH    FORMS    OF     LOCAL     DTSKASR    AFFECTING 

DLSURHERH.  Ill  onoHvo  vol.  of  470  p.  Cloth, 8:i.li5.    PRINCIPALLY    THK    ORGANS    OF    GENKRA- 

LEE'8  LECTURES  ON  SYPHILIS  AND  SOME  |  TION.    In  one  8vo.  vol.  of  240  pages.    Cloth,  S'2.25. 


26 


Lea  Brothers  &  Co.'s  Publications — Diseases  of  Skin. 


MYJDB,  J.  WEVINS,  A.  M.,  M.  D., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Rush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.    For  the  use  of  Students  and 
Practitioners.     In  one  handsome  octavo  volume  of  570  i)ages,  with  66  beautiful  and  elab- 
orate illustrations.     Cloth,  $4.25 ;  leather,  |5.25. 
The  author  has  given  the  student  and  practi-  I  cian  in  active  practice.    In  dealing  with   these 

questions  the  author  leaves  nothing  to  the  pre- 


tioner  a  work  admirably  adapted  to  the  wants  of 
each.  We  can  heartily  commend  the  book  as  a 
vahiable  addition  to  our  literature  and  a  reliable 
guide  to  students  and  practitioners  in  their  studies 
and  practice. — Am.  Journ.  of  Med.  Sci.,  July,  18S3. 

Especially  to  be  praised  are  the  practical  sug- 
gestions as  to  what  may  bo  called  the  common- 
sense  treatment  of  eczema.  It  is  quite  impossible 
to  exaggerate  the  judiciousness  with  which  the 
formuI.?8  for  the  external  treatment  of  eczema  are 
selected,  and  what  is  of  equal  importance,  the  full 
and  clear  instructions  for  their  use. — London  Medi- 
cal Times  and  Gazette,  July  28,  188-3. 

The  work  of  Dr.  Hyde  will  be  awarded  a  high 
position.  The  student  of  medicine  will  find  it 
peculiarlj'  adapted  to  his  wants.     Notwithstanding 


sumed  knowledge  of  the  reader,  but  enters  thor- 
oughly into  the  most  minute  description,  so  that 
one  is  not  only  told  what  should  be  done  under 
given  conditions  but  how  to  do  it  as  well.  It  is 
tlierefore  in  the  best  sense  "a  practical  treatise." 
That  it  is  comprehensive,  a  glance  at  the  index 
will  sliow. — Maryland  Medical  Journal,  July  7,  1883. 
Professor  Hyde  has  long  been  known  as  one  of 
the  most  intelligent  and  enthusiastic  representa- 
tives of  dermatology  in  the  west.  His  numerous 
contributions  to  the  literature  of  this  specialty 
have  gained  for  him  a  favorable  recognition  as  a 
careful,  conscientious  and  original  observer.  The 
remarkable  advances  made  in  our  knowledge  of 
diseases  of  the  skin,  especially  from  the  stand- 


the  extent  of  the  suljject  to  which  it  is  devoted,  I  point  of  pathological  histology  and  improved 
yet  it  is  limited  to  a  single  and  not  very  large  vol-  methods  of  treatment,  necessitate  a  revision  of 
ume,  without  omitting  a  proper  discussion  of  the  the  older  textbooks  at  short  intervals  in  order  to 
topics.  The  conciseness  of  the  volume,  and  the  bring  them  up  to  the  standard  demanded  by  the 
setting  forth  of  only  what  can  be  held  as  facts  will  march  of  science.  This  last  contribution  of  Dr. 
also  make  it  acceptable  to  general  practitioners.  Hyde  is  an  eflJ'ort  in  this  direction.  He  has  at- 
— Cincinnati  Medical  News,  Feb.  1883.  .  tempted,  as  he  informs  us,  the  task  of  presenting 

The  aim  of  the  author  has  been  to  present  to  his  j  in  a  condensed  form  the  results  of  the  latest  ob- 
readers  a  work  not  only  expounding  the  most  |  servation  and  experience.  A  careful  examination 
modern  conceptions  of  his  subject,  but  presenting  ;  of  the  work  convinces  us  that  he  has  accomplished 
what  is  of  standard  value.  He  has  more  especially  i  his  task  with  painstaking  fidelity  and  with  a  cree- 
devoted  its  pages  to  the  treatment  of  disease,  and  ,  itable  result. — Journal  of  Cutaneous  and  Venereal 
by  his  detailed  descriptions  of  therapeutic  meas-  i  Diseases,  June,  1883. 
ures  has  adapted  them  to  the  needs  of  the  physi-  | 


FOX,  T.,  M.I).,  F.M.C.r.,  and  FOX,  T,C.,B.A,,  M,Il.C.S,, 

Physician  to  the  Department  for  Skin  Diseases,  Physician  for  Diseases  of  the  Skin  to  the 

University  College  Hospital,  London.  Westminster  Hospital,  London. 

An  Epitome  of  Skin  Diseases.  With  Pormulss.  For  Students  and  Prac- 
titioners. Third  edition,  revised  and  enlarged.  In  one  very  handsome  12mo.  volume 
of  238  pages.     Cloth,  $1 .25. 

The  third  edition  of  this  convenient  handbook  |  manual  to  lie  upon  the  table  for  instant  reference, 
calls  for  notice  owing  to  the  revision  and  expansion  |  Its  alphabetical  arrangement  is  suited  to  this  use, 
«tV,;^v,  ;+  !,„.,  „„^^,.„„„„    Tu^  „„„„ „i  „f  „!.;„  ,  i^pj.  j^j]  p,^g  j^g^g  ^Q  know  is  the  name  of  the  disease, 


which  it  has  undergone.  Thearrangement  of  skin 
diseases  in  alphabetical  order,  which  is  the  method 
of  classification  adopted  in  this  work,  becomes  a 
positive  advantage  to  the  student.  The  book  is 
one  which  we  can  strongly  recommend,  not  only 
to  students  but  also  to  practitioners  who  require  a 
compendious  summary  of  the  present  state  of 
dermatology.— ^riii's/i  Medical  Journal,  July  2, 1883. 
We  cordially  recommend  Fox's  Epitome'to  those 
whose  time  is  limited  and  who  wish    a   handy 


and  here  are  its  description  and  the  appropriate 
treatment  at  hand  and  ready  for  instant  applica- 
tion. The  present  edition  has  been  very  carefully 
revised  and  a  number  of  new  diseases  are  de- 
scribed, while  most  of  the  recent  additions  to 
dermal  therapeutics  find  mention,  and  the  formu- 
lary at  the  end  of  the  book  has  been  considerably 
augmented. — The  Medical  News,  December,  1883. 


MOMMIS,  3IALCOLM,  F.  M.  C.  S., 

Joint  Lecturer  on  Dermatology  at  St.  Mary''s  Hospital  Medical  School,  London. 
Skin  Diseases ;  Including  their  Definitions,  Symptoms,  Diagnosis,  Prognosis,  Mor- 
bid Anatomy  and  Treatment.     A  Manual  for  Students  and  Practitioners.     In  one  12mo. 
volume  of  316  pages,  with  illustrations.     Cloth,  |1.75. 

for  clearness  of  expression  and  methodical  ar- 
rangement is  better  adapted  to  promote  a  rational 
conception  of  dermatology — a  branch  confessedly 
difficult  and  perplexing  to  the  beginner. — St.  Louis 
Courier  of  Medicine,  April,  1880. 

The  writer  has  certainly  given  in  a  small  compass 
a  large  amount  of  well-compiled  information,  and 
his  little  book  compares  favorably  with  any  other 
which  has  emanated  from  England,  while  in  many 

Eoints  he  has  emancipated  himself  from  the  stub- 
ornly  adhered  to  errors  of  others  of  his  country- 
men. There  is  certainly  excellent  material  in  the 
book  which  will  well  repay  perusal. — Boston  Med. 
and  Surg.  Journ.,  March,  1880. 


To  physicians  who  would  like  to  know  something 
about  skin  diseases,  so  that  when  a  patient  pre- 
sents himself  for  relief  they  can  make  a  correct 
diagnosis  and  prescribe  a  rational  treatment,  we 
unhesitatingly  recommend  this  little  book  of  Dr. 
Morris.  The  affections  of  the  skin  are  described 
in  a  terse,  lucid  manner,  and  their  several  charac- 
teristics so  plainly  set  forth  that  diagnosis  will  be 
easy.  The  treatment  in  each  case  is  such  as  the 
experience  of  the  mosteminent  dermatologists  ad- 
vises.— Cincinnati  Medical  Neivs,  April,  1880. 

This  is  emphatically  a  learner's  book;  for  we 
can  safely  say,  that  in  the  whole  range  of  medical 
literature  there  is  no  book  of  a  like  scope  which 


WILSON,  FMAS3IUS,  F.B.S. 

The  Student's  Book  of  Cutaneous  Medicine  and  Diseases  of  the  Skin. 

In  one  handsome  small  octavo  volume  of  535  pages.     Cloth,  $3.50. 

sillieu,  tsomas,  m.  d.. 

Physician  to  the  Skin  Department  of  University  College,  London. 
Handbook  of  Skin  Diseases;  for  Students  and  Practitioners.    Second  Ameri- 
can edition.     In  one  12mo.  volume  of  353  pages,  with  plates.     Cloth,  $2.25. 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women. 


27 


AW  AMBJRICAW  STSTJEM  OF  GYNAECOLOGY. 

A  System  of  Gynseeology,  in  Treatises  by  Various  Authors.  Edited 
by  Matthew  D.  Mann,  M.  D.,  Professor  of  Obstetrics  and  Gynaecology  in  the  Uni- 
versity of  Buffalo,  N.  Y.     In  two  handsome  octavo  volumes,  richly  illustrated.     In  active 

preparation. 

LIST  OF  CONTRIBUTORS. 


WILLIAM  H.  BAKER,  M.  D., 
FORDYCE  BARKER,  M.  D., 
ROBERT  BATTEY,  M.  D., 
SAMUEL  C.  BUSEY,  M.  D., 
HENRY  F.  CAMPBELL,  M.  D., 
HENRY  C.  COE,  M.  D,, 
E.  C.  DUDLEY,  M.  D., 
GEORGE  J.  ENGBLMANN,  M.  D., 
Aenry  F.  GARRIGUES,  M.  D., 
WILLIAM  GOODELL,  M.  D., 
EGBERT  H.  GRANDIN,  M.  D., 
SAMUEL  W.  GROSS,  M.  D., 
JAMES  B.  HUNTER,  M.  D., 
A.  REEVES  JACKSON,  M.  D., 


EDWARD  W.  JENKS,  M.  D., 
WILLIAM  T.  LUSK,  M.  D., 
MATTHEW  D.  MANN,  M.  D., 
ROBERT  B.  MAURY,  M.  D., 
PAUL  F.  MUNDE,  M.  D., 
C.  D.  PALMER,  M.  D., 
WILLIAM  M.  POLK,  M.  D., 
THADDEUS  A.  REAMY,  M.  D., 
A.  D.  ROCKWELL,  M.  D., 
ALEX.  J.  C.  SKENE,  M.  D., 
R.  STANSBURY  SUTTON,  A.  M., 
T.  GAILLARD  THOMAS,  M.  D., 
ELY  VAN  DE  WARKER,  M.  D., 
W.  GILL  WYLIE,  M.  D. 


TSOMAS,  T.  GAILLAMD,  M.  D., 

Pr'ofessor  of  Diseases  o/  Women  in  the  College  of  Physicians  and  Surgeons,  N.  Y. 

A  Practical  Treatise  on  the  Diseases  of  Women.  Fifth  edition,  thoroughly 
revised  and  rewritten.  In  one  large  and  handsome  octavo  volume  of  810  pages,  with  266 
illustrations.     Cloth,  $5.00 ;  leather,  $6.00 ;  very  handsome  half  Russia,  raised  bands,  $6.50. 

vious  one.  As  a  book  of  reference  for  the  busy 
practitioner  it  is  unequalled. — Boston  Medical  and 
Surgical  Journal,  April  7, 1880. 

It  has  been  enlarged  and  carefully  revised.  It  is 
a  condensed  encycYopEedia  of  gynsecological  medi- 
cine. The  style  of  arrangement,  the  masterly 
manner  in  which  each  subject  is  treated,  and  the 
honest  convictions  derived  from  probably  the 
largest  clinical  experience  in  that  specialty  of  any 
in  this  country,  all  serve  to  commend  it  in  the 
highest  terms  to  the  practitioner. — Nashville  Jour., 
of  Med.  and  Surg.,  Jan.  1881. 

That  the  previous  editions  of  the  treatise  of  Dr. 
Thomas  were  thought  worthy  of  translation  into 
German,  French,  Italian  and  Spanish,  is  enough 
to  give  it  the  stamp  of  genuine  merit.  At  home  it 
has  made  its  way  into  the  library  of  every  obstet- 
rician and  gynsecologist  as  a  safe  guide  to  practice. 
No  small  number  of  additions  have  been  made  to 
the  present  edition  to  make  it  correspond  to  re- 


The  words  which  follow  "  fifth  edition"  are  in 
this  case  no  mere  formal  announcement.  The 
alterations  and  additions  which  have  been  made  are 
both  numerous  and  important.  The  attraction 
and  the  permanent  character  of  this  book  lie  in 
the  clearness  and  truth  of  the  clinical  descriptions 
of  diseases;  the  fertility  of  the  author  in  thera- 
peutic resources  and  tlie  fulness  with  which  the 
details  of  treatment  are  described;  the  definite 
character  of  the  teaching ;  and  last,  bvit  not  least, 
the  evident  candor  which  pervades  it.  We  would 
also  particularize  the  fulness  with  wMch  the  his- 
tory of  the  subject  is  gone  into,  which  makes  the 
book  additionally  interesting  and  gives  it  value  as 
a  work  of  reference. — London  Medical  Times  and 
Gazette,  July  30, 1881. 

The  determination  of  the  author  to  keep  his 
book  foremost  in  the  rank  of  worlvs  on  gynaecology 
is  most  gratifying.  Recognizing  the  fact  that  this 
can  only  be  accomplished  by  frequent  and  thor- 


ough revision,  he  has  spared  no  pains  to  make  the  i  cent  improvements  in  treatment. — Pacific  Medical, 
present  edition  more  desirable  even  than  the  pre-  I  and  Surgical  Journal,  Jan.  1881. 


BJDIS,  ABTHUM  W.,  M.  D.,  JLond.,  F.R.  CI*.,  M.B.  C.  S., 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 

The  Diseases  of  Women.  Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.  A  Manual  for  Students  and  Practitioners.  In  one  handsome 
octavo  volume  of  576  pages,  witli  148  illustrations.     Cloth,  $3.00 ;  leather,  $4.00. 

The  greatest  pains  have  been  taken  with  the 
sections  relating  to  treatment.    A  liberal  selection 


It  is  a  pleasure  to  read  a  book  so  thoroughly 
good  as  this  one.  The  special  qualities  which  are 
conspicuous  are  thoroughness  in  covering  the 
whole  ground,  clearness  of  description  and  con- 
cineness  of  statement.  Another  marked  feature  of 
the  book  is  the  attention  paid  to  the  details  of 
many  minor  surgical  operations  and  procedures, 
as,  for  instance,  the  use  of  tents,  application  of 
leeches,  and  use  of  hot  water  injections.  These 
are  among  the  more  common  methods  of  treat^ 
ment,  ana  yet  very  little  is  said  about  them  in 
many  of  the  textrbooks.  The  book  is  one  to  be 
warmly  recommended  e.ipeeially  to  students  and 
general  practitioners,  who  need  a  concise  but  com- 
plete r«(«m^  of  the  whole  subject.  Specialists,  too, 
will  find  many  n.^eful  hints  in  its  pages. — Boston 
MrA.  and  Surg.  Journ.,  March  2,  1882. 


of  remedies  is  given  for  each  morbid  condition, 
the  strength,  mode  of  application  and  other  details 
being  fully  explained.  The  descriptions  of  gynse- 
cological  manipulations  and  operations  are  full, 
clear  and  practical.  Much  care  has  also  been  be- 
stowed on  the  parts  of  the  book  which  deal  with 
diagnosis — we  note  especially  the  pages  dealing 
with  the  diiferentiation,  one  from  another,  of  the 
different  kinds  of  abdominal  tumors.  The  prac- 
titioner will  therefore  find  in  this  book  the  kind 
of  knowledge  he  moat  needs  in  his  daily  work,  and 
he  will  be  pleased  with  the  clearness  and  fulness 
of  the  information  there  given. —  The  Practitioner, 
Feb.  1882. 


BABNBS,  ROBBBT,  M.  JD.,  B.  B,  C,  P., 

Obntetric  Pliynicum  to  SI.  Thomas'  Hospital,  London,  etc. 

A  Clinical  Exposition  of  the  Medical  and  Surgical  Diseases  of  Women. 
In  one  handsome  octavo  vohurie,  with  numerous  illustrations.     New  edition.    Preparing. 

WBST,  CHABLBS,  M.  D. 

Lectures  on  the  Diseases  of  Women.     Third  American  from  the  third  Lon- 
don edition.     In  one  octavo  vohime  of  54.'i  pages.     Cloth,  $3.75;  leather,  $4.76. 


28         Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women,  Midwfy. 
EMMET,  THOMAS  ADDIS,  31.  !>.,  LL.  D,, 

Surgeon  to  the  Woman^s  Hospital,  New  York,  etc. 

The  Principles  and  Practice  of  Gyngecology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  New  (third)  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  §5 ;  leather,  $6 ; 
very  handsome  half  Russia,  raised  bands,  §6.50. 


We  are  in  doubt  whether  to  congratulate  the 
author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  work. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  con.'-picuously  distinguished  himself 
as  a  bold  and  successful  operator,  and  who  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 


once  a  credit  to  its  author  and  to  American  med- 
ical literature.  We  repeat  that  it  is  a  book  to  be 
studied,  and  one  that  is  indispensable  to  every 
practitioner  giving  any  attention  to  gynsecology. — 
American. Journal  of  the  Medical  Sciences,  April,  1885. 
The  time  has  passed  when  Emmet's  Oi/ncecologi/ 
was  to  be  regarded  as  a  book  for  a  single  country 
or  for  a  single  generation.    It  has  always  been  his 


the  privilege  thus  offered  them  of  perusing  the  '  aim  to  popularize  gynecology,  to  bring  it  within 
views  and  practice  of  the  author.  His  earnestness  ]  easy  reach  of  the  general  practitioner.  The  orig- 
of  purpose  and  conscientiousness  are  manifest,  inaiity  of  the  ideas,  aside  from  the  perfect  con- 
He  gives  not  only  his  individual  experience  but  fidence  which  we  feel  in  the  author's  statements, 
endeavors  to  represent  the  actual  state  of  gynee-  compels  our  admiration  and  respect.  We  may 
cological  science  and  art. — British  Medical  Jour-  well  talc^  an  honest  pride  in  Dr.  Emmet's  work 
nal,  yla.y  10,  1.SS.5.  and  feel  that  his  book  can  hold  its  own  against  the 

Iso  jot  or  tittle  of  the  high  praise  bestowed  upon  criticism  of  two  continents.  It  represents  all  that 
the  first  edition  is  abated.  It  is  still  a  book  of  is  most  earnest  and  most  thoughtful  in  American 
marked  personality,  one  based  upon  large  clinical  |  gj^nsecology.  Emmet's  work  will  continue  to 
experience,  containing  large  and  valuable  ad-  reflect  the  "individuality,  the  sterling  integrity  and 
ditions  to  our  knowledge,  evidently  written  not  |  the  kindly  heart  of  its  honored  author  long  after 
only  with  honesty  of  purpose,  but  with  a  conscien- [  smaller  books  have  been  forgotten. — A7nerican 
tious  sense  of  responsibility,  and  a  book  that  is  at  1  Journal  of  Obstetrics,  May,  1885. 


DUWCAW,  J,  MATTHEWS,  M,D.,  LL.  D.,  F.  M.  S.  E.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.     In  one  handsome  octavo  volume  of  175  pages.     Cloth,  $1.50. 

They  are  in  every  way  worthy  of  their  author  ;  I  rule,  adequately  handled  in  the  text-books ;  others 
indeed,  we  look  upon  them  as  among  the  most  i  of  them,  while  bearing  upon  topics  that  are  usually 
valuable  of  his  contributions.  They  are  all  upon  ■  treated  of  at  length  in  such  works,  yet  bear  such  a 
matters  of  great  interest  to  the  general  practitioner,  stamp  of  individuality  that  they  deserve  to  be 
Some  of  them  deal  with  subjects  that  are  not,  as  a  I  widely  read. — N.  Y.  Medical  Journal,  March,  1880. 

31  AY,    CHAMLES  H.,  M.  D. 

Late  House  Surgeon  to  Mount  Sinai  Hospital,  New  York. 

A  Manual  of  the  Diseases  of  Women.  Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynsecology.  In  one  12mo.  volume  of  342  pages. 
Cloth,  $1.75.     JvM  ready. 


Bledical  students  will  find  this  work  adapted  to 
their  wants.  Also  practitioners  of  medicine  will 
find  it  exceedingly  convenient  to  consult  for  the 
purpose  of  refreshing  their  minds  upon  the  lead- 
ing points  of  a  gynEeeologieal  subject.  By  syste- 
matic condensation,  the  omission  of  disputed  ques- 


tions, and  the  presentation  only  of  accepted  views, 
it  constitutes  a  very  satisfactory  exposition  of  the 
leading  principles  of  gynaecology  as  they  are  un- 
derstood at  the  present  time. — Cincinnati  Medical 
News,  Nov.  1885. 


HODGE,  HVGHL.,  M.  D., 

Emeritus  Professor  of  Obstetrics,  etc.,  in  the  University  of  Pennsylvania. 
On  Diseases  Peculiar  to  Women;  Including  Displacements  of  the  Uterus. 
Second  edition,  revised  and  enlarged.     In  one  beautifully  printed  octavo  volume  of  519 
pages,  with  original  illustrations.     Cloth,  $4.50. 

By  the  Same  Author. 

The  Principles  and  Practice  of  Obstetrics.  Illustrated  with  large  litho- 
graphic plates  containing  159  figures  from  original  photographs,  and  with  numerous  wood- 
cuts. In  one  large  quarto  volume  of  542  doul)le-columned  pages.  Strongly  bound  in 
cloth,  $14.00.  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address, 
ft-ee  by  mail,  on  receipt  of  six  cents  in  postage  stamps. 

BAMSBOTHAM,  FBAJSTCIS  H.,  31.  D. 

The  Principles  and  Practice  of  Obstetric  Medicine  and  Surgery; 

In  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly  revised 
by  the  Author.  With  additions  by  AV.  V.  Keating,  M.  D.,  Professor  of  Obstetrics,  etc., 
in  the  Jefferson  j\[edical  College  of  Philadelphia.  In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full-page  plates  and  43  woodcuts  in  the  text,  contain- 
ing in  all  nearly  200  beautiful  figures.     Strongly  bound  in  leather,  with  raised  bands,  $7. 

WINCKEL,F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed, 

For  Students  and  Practitioners.  Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  by  J.  E.  Chadwick,  M.  D.     Octavo  484  pages.     Cloth,  $4.00. 

ASHWELL'S  PRACTICAL  TREATISE  ON  THE  1  AND  OTHER  DISEASES  PECULIAR  TO  WO- 
DISEASES  PECULIAR  TO  WOMEN.  Third  MEN.  In  one? vo.  vol.  of  464  pages.  Cloth,  82.50. 
American  from  the  third  and  revised  London  !  MEIitS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth.  S-3.50.     1      MENT  OF  CHILDBED  FEVER.    In  one  8vo. 

CHURCHILL  ON    THE    PUERPERAL  FEVER  1      volume  of  346  pages.    Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Midwifery.  29 

BARNBS,  MOBBUT,  M.  D.,   cmd   FAWCOUBT,   M.  D,, 

Phys.  to  the  General  Lying-in  Hosp.,  Lond.  Obstetric  Phys.  to  St.  Thomas'  Hasp.,  Land. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  contributed  by 
Prof.  Milnes  Marshall.  In  one  handsome  octavo  volume  of  872  pages,  with  231  illus- 
trations.   Cloth,  ^5 ;  leather,  $6.      Just  ready. 

This  system  will  be  eagerly  sought  for,  not  only  ]  ble  teacher  and  trusted  accoucheur,  should  embody 
on  account  of  its  intrinsic  merit,  but  also  because  ■  within  a  single  treatise  the  system  which  he  has 
the  reputation  which  the  elder  Barnes,  in  particu-  taught  and  in  practice  tested,  and  which  is  the  out- 
lar,  has  secured,  carries  with  it  the  conviction  that  :  come  of  a  lifetime  of  earnest  labor,  careful  obser- 
any  book  emanating  from  him  is  necessarily  sound  j  vation  and  deep  study.  The  result  of  this  arrange- 
in  teaching  and  conservative  in  practice.  It  is  in-  |  ment  is  the  production  of  a  work  which  rises  above 
deed  eminently  fitting  that  a  man  who  has  done  so  criticism  and  which  in  no  respect  need  yield  the 
much  towards  systematizing  the  obstetric  art,  who  !  palm  to  any  obstetrical  treatise  hitherto  published, 
for  so  many  years  has  been  widely  known  as  a  eapa-  j  — American  Journal  of  Obstetrics,  Feb.  1886. 


PLATFAIM,  W.  S.,  M.  D.,  F.  JS.  C.  F,, 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc, 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  New  (fourth) 
American,  from  the  fifth  English  edition.  Edited,  with  additions,  by  Robert  P.  Har- 
ris, M.  D.  In  one  handsome  octavo  volume  of  654  pages,  with  3  plates  and  201  engrav- 
ings    Cloth,  $4 ;  leather,  $5 ;  half  Russia,  $5.50.     Just  ready. 


This  still  remains  a  favorite  in  America,  not 
only  because  the  author  is  recognized  as  a  safe 
guide  and  eminently  progressive  man,  but  also  as 
sparing  no  effort  to  make  each  successive  edition 
a  faithful  mirror  of  the  latest  and  best  practice. 
A  work  so  frequently  noticed  as  the  present 
requires  no  further  review.  We  believe  that  this 
edition  is  simply  the  forerunner  of  many  others, 
and  that  the  demand  will  keep  pace  with  the 
supply. — America?}-  Journal  of  Obstetrics,  Nov.  1885. 
i«  jSinee  its  first  publication,  only  eight  j'ears  ago, 
it  has  rapidly  become  the  favorite  text-book,  to 
the  practical  exclusion   of   all  others.    A 


for  students  have  very  much  to  boast  of  in  this 
respect. — Medical  Record. 

In  the  short  time  that  this  excellent  and  highly 
esteemed  work  has  been  before  the  profession  it 
has  reached  a  fourth  edition  in  this  country  and  a 
fifth  one  in  England.  This  fact  alone  speaks  in 
high  praise  of  it,  and  it  seems  to  us  that  scarcely 
more  need  be  said  of  it  in  the  way  of  endorsement 
of  its  value.  As  a  text  book  for  students  and  for 
the  uses  of  the  general  practitioner  there  is  no 
work  on  obstetrics  superior  to  the  work  of  Dr. 
Playfair.  Its  teachings  are  practical,  written  in 
plain  language,  and  afford  a  correct  understanding 
of  the  art  of  midwifery.  No  one  can  be  disap- 
pointed in  it. — Cincinnati  Medical  News,  June,  1885. 

D.  Fdin.f 

Clinical  Professor  of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevue  Hospital  Medical  College, 
New  York,  Honorary  Fellow  of  the  Obstetrical  Societies  of  London  and  Edinburgh,  etc.,  etc. 

Obstetrical  and  Clinical  Essays.    In  one  handsome  12mo.  volume  of  about 
300  pages.     Preparing. 

KING,  A,  F.  A.,  M.  If., 

Professor  of  Obstetrics  and  Diseases  of  Women  m  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     Second  edition.    In  one  very  handsome  12mo.  volume 
of  331  pages,  with  59  ilhistrations.     Cloth,  $2.00. 

It  must  be  acknowledged  that  this  is  just  what 
it  pretends  to  be — a  sound  guide,  a  portable  epit- 
ome, a  work  in  which  only  indispensable  matter 
ha-s  oeen  presented,  leaving  out  all  padding  and 
chaff,  and  one  in  which  the  student  will  find  pure 
wheat  or  condensed  nutriment. — New  Orleans  Med- 
ical and  S'irgical  .Journal,  May,  1884. 

In  a  eeries  of  short  paragraphs  and  by  a  con- 


measure  of  its  popularity  is  due  to  the  clear  and    of  the  art  of  midwifery, 
easy  style  in  which  it  is  written.    Few  text-books    pointed  in  it. — Cincinnati 

BABKFIt,  FOnnYCE,  A,  M.,  M.  JD.,  11, 

Clinical  Professor  of  Midwifery  and  the  Diseases  of  Women  in  the  Bellevu 

New  York,  Honorary  Fellow  of  the  Obstetrical  Societies  of  London  and  1 

Obatfttrica.l   and   Clininm.l   "Rssavs.     In  one  handsome   15 


densed  style  of  composition,  the  writer  has  pre- 
sented a  great  deal  of  what  it  is  well  that  every 
obstetrician  should  know  and  be  ready  to  practice 
or  prescribe.  The  fact  that  the  demand  for  the 
volume  has  been  such  as  to  exhaust  the  first 
edition  in  a  little  over  a  year  and  a  half  speaks 
well  for  its  popularity. — American  Journal  of  the 
Medical  Sciences,  April,  1884. 


BABNFS,  FAWCOUBT,  M.  D,, 

Obstetric  Physician  to  St.  Thomas'  Hospital,  London. 

A  Manual  of  Midwifery  for  Midwives  and  Medical  Students.    In  one 
royal  12mo.  volume  of  197  pages,  with  50  illustrations.     Cloth,  $1.25. 


FABVIN,  THEOFSILVS,  M.  J>.,  LL,  J)., 

ProfcHsor  of  Obstetrics  awl  the  Diseases  of  Women  and  Children  in  the  Jefferson  Medical  College. 
A  Treatise  on  Midwifery.     In  one  very  handsome  octavo  volume  of  about  550 
pages,  with  numercnis  illustrations.     Preparing. 

FABBY,  JOHN  S.,  M.  IJ., 

Obnt.etricinn  to  lite  I'hilrulclphia  Hospital,  Vice-President  of  the  Obstet.  Society  of  Philadelphia. 
Extra  -  Uterine  Pregnancy:  Its   (Jlinical   History,    Diagnosis,   Prognosis   and 
Treatment.     In  oik;  liandsoriie  octavo  volume  of  272  pages.     Cloth,  $2.50. 

TANNFB,  THOMAS  IIAWKFS,  M,  I), 

On  the  Signs  and  Diseases  of  Pregnancy.    First  American  fnjm  the  second 
English  edition.     (Jctavo,  490  pages,  with  4  colored  plates  and  16  woodcuts.     Cloth,  $4.25. 


30 


Lea  Brothers  &  Co.'s  Publications — Midwfy.,  Dis.  CMldn. 


LBISSMAN,  WILLIAM,  M.  D., 

Reqlus  Professor  of  Midwifery  in  the  University  of  Glasgow,  etc. 

A  System  of  Midwifery,  Including  the  Diseases  of  Pregnancy  and  the 
Puerperal  State.  Third  American  edition,  revised  by  the  Author,  with  additions  by 
John  S.  Parry,  M.  D.,  Obstetrician  to  the  Philadelphia  Hospital,  etc.  In  one  large  and 
very  handsome  octavo  volume  of  740  pages,  with  205  illustrations.  Cloth,  $4.50 ;  leather, 
$5.50 ;  very  handsome  half  Russia,  raised  bands,  $6.00. 

The  author  is  broad  in  his  teachings,  and  dis- 
cusses briefly  the  comparative  anatomy  of  the  pel- 


vis and  the  mobility  of  the  pelvic  articulations. 
The  second  chapter  is  devoted  especially  to 
the  SbUdy  of  the  pelvis,  while  in  the  third  the 
female  organs  of  generation  are  introduced. 
The  structure  and  development  of  the  ovum  are 
admirably  described.  Then  follow  chapters  upon 
the  various  .subjects  embraced  in  the  study  of  mid- 
wifery. The  descriptions  throughout  the  work  are 
plain  and  pleasing.    It  is  sufficient  to  state  that  in 


this,  the  last  edition  of  this  well-known  work,  every 
recent  advancement  in  this  field  has  been  brought 
forward. — Physician  and  Surgeon,  Jan.  1880. 

To  the  American  student  the  work  before  us 
must  prove  admirably  adapted.  Complete  in  all  its 
parts,  essentially  modern  m  its  teachmgs,  and  with 
demonstrations  noted  for  clearness  and  precision, 
it  will  gain  in  favor  and  be  recognized  as  a  work 
of  standard  merit.  The  work  cannot  fail  to  be 
popular  and  is  cordially  recommended. — N.  O. 
Med.  and.  Surg.  Journ.,  March.  1880. 


LAJS^Dis,  mbnuy  g,,  a.  m.,  m.  n., 

Professor  of  Obstetrics  and  the  Diseases  of  Women  in  Starling  Medical  College,  ColumbuSfO. 

The  Management  of  Labor,  and  of  the   Lying-in  Period.     In  one 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.     Cloth,  $1.75.     Just  ready. 


This  is  a  book  we  can  heartily  recommend. 
The  author  goes  much  more  practically  into  the 
details  of  the  management  of  labor  than  most 
text-books,  and  is  so  readable  throughout  as  to 
tempt  any  one  who  should  happen  to  commence 
the  book  to  read  it  through.  The  author  pre- 
supposes a  theoretical  knowledge  of  obstetrics, 


and  has  consistently  excluded  from  this  little 
work  everj'thing  that  is  not  of  practical  use  in  the 
lying-in  room.  We  think  that  if  it  is  as  widely 
read  as  it  deserves,  it  will  do  much  to  improve 
obstetric  practice  in  general. — Neiv  Orleans  Medi- 
cal and  Surgical  Journal,  Mar.  1886. 


SMITJET,  J.  LBWIS,  M.  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Belleviie  Hospital  Medical  College,  N.  T. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  New  (sixth) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  867 
pages,  with  40  illustrations.     Cloth,  $4.50;  leather,  $5.50  ;  half  Eussia,  $6.00.     Just  ready. 

No  better  work  on  children's  diseases  could  be  I  ranked  with  the  foremost.  The  autnor  has  con- 
placed  in  the  hands  of  the  student,  containing,  as  I  tinuously  kept  in  view  the  eminently  practical 
it  does,  a  very  complete  account  of  the  symptoms  !  character  of  his  work,  which  made  it  so  popular 
and  pathology  of  the  diseases  of  early  life,  and  '  in  former  editions.  A  very  commendable  feature 
possessing  the  further  advantage,  in  which  it  I  is  the  increasing  space  devoted  to  therapeutics,  in 
stands  alone  amongst  other  works  on  its  subject,  |  which  the  author,  besides  drawing  on  his  own 
of  recommending  treatment  in  accordance  with  !  rich  mine  of  clinical  experience,  gives  in  addi- 
the  most  recent  therapeutical  views.— British  and  '  tion,  the  most  improved  forms  of  treatment  as 
Foreign  Medico-Chirurgical  Review.  \  gleaned    from    Ihe   works   of  others.— Cincinnati 

Among  American    medical    text-books    which    Lancet  and  Clinic,  Feb.  27, 1886. 
have  become  classic.  Smith  on  Children  may  be  I 

KEATING,  J0H:N3L,  31.  D,, 

Lecturer  on  the  Diseases  vf  Children  at  the  University  of  Pennsylvania,  etc. 

The  Mother's  Guide  in  the  Management  and  Feeding  of  Infants.    In 

one  handsome  12mo.  volume  of  118  pages.     Cloth,  $1.00. 


Works  like  this  one  will  aid  the  physician  im- 
mensely, for  it  saves  the  time  he  is  constantly  giv- 
ing his  patients  in  instructing  them  on  the  sub- 
jects here  dwelt  upon  so  thoroughly  and  prac- 
tically. Dr.  Keating  has  written  a  practical  book, 
has  carefully  avoided  unneces.sary  repetition,  and 


successfully  instructed  the  mother  in  such  details 
of  the  treatment  of  her  child  as  devolve  upon  her. 
He  has  studiously  omitted  giving  prescriptions, 
and  instructs  the  mother  when  to  call  upon  the 
doctor,  as  his  duties  are  totally  distinct  from  hers. 
— American  Joxirnal  of  Obstetrics,  October,  1881. 


OWBN,  BDMTJNI),  M.  B.,  F.  M.  C.  S,, 

Surgeon  to  the  Children's  Hospital,  Ghreat  Ormond  St.,  London. 


Surgical  Diseases  of  Children. 

cbromo-lithographic  plates  and  85  woodcuts, 
ical  Manuals,  page  4. 

We  look  with  considerable  interest  at  the  work, 
coming  as  it  does  from  the  hands  of  a  surgeon  of 
special  experience  in  this  subject  and  recognized 
as  an  able  teacher  as  well  as  a  peculiarly  practical 


In  one  12mo.  volume  of  525  pages,  with  4 
Just  ready.     Cloth,  $2.     See  Series  of  Clin- 

surgeon.  It  certainly  may  be  looked  to  as  the  type 
of  a  practical  manual. — London  Medical  Record, 
Januarj'  15,  1886. 


WEST,  CSARLBS,  31.  D., 

Physician  to  the  Hospital  for  Sick  Children,  London,  etc. 

Lectures  on  the  Diseases  of  Infancy  and  Childhood.    Fifth  American 
from  6th  English  edition.   In  one  octavo  volume  of  686  pages.   Cloth,  $4.50 ;  leather,  $5.50. 

By  the  Same  Author. 

On  Some  Disorders  of  the  Nervous  System  in  Childhood.    In  one  small 
12mo.  volume  of  127  pages.     Cloth,  $1.00. 


CONDIE'S    PRACTICAL    TREATISE    ON    THE 
DISEASES  OF  CHILDREN.    Sixth  edition,  re- 


vised and  augmented.    In  one  octavo  volume  of 
779  pages.    Cloth,  $5.25 ;  leather,  $6.25. 


J 


Lea  Brothers  &  Co.'s  Publications — Med.  Jui-ls.,  Miscel. 


31 


TIDY,  CJEEAnLES  MEYMOTT,  M.  B.,  F.  C.  S,, 

Professor  of  Chemistry  and  of  Forensic  Medicine  and  Public  Health  at  the  London  Hospital,  etc. 

Legal  Medicine.  Volume  II.  Legitimacy  and  Paternity,  Pregnancy,  Abor- 
tion, Eape,  Indecent  Exposure,  Sodomy,  Bestiality,  Live  Birth,  Infanticide,  Asphyxia, 
Drowning,  Hanging,  Strangulation,  Suffocation.  ]\Iaking  a  very  handsome  imperial  oc- 
tavo volume  of  529  pages.     Cloth,  $6.00;  leather,  §7.00. 

Volume  I.  Containing  664  imperial  octavo  pages,  with  two  beautiful  colored 
plates.     Cloth,  $6.00 ;  leather,  $7.00. 

The  satisfaction  expressed  with  the  first  portion  [  tables  of  cases  appended  to  each  division  of  the 
of  this  work  is  in  no  wise  lessened  by  a  perusal  of  |  subject,  must  have  cost  the  author  a  prodigious 
the  second  volume.  We  find  it  characterized  by  i  amount  of  labor  and  research,  but  they  constitute 
the  same  fulness  of  detail  and  clearness  of  ex-  ;  one  of  the  most  valuable  features  of  the  book, 
pression  which  we  had  occasion  so  highly  to  com-  i  especially  for  reference  in  medico-legal  trials. — 
mend  in  our  former  notice,  and  which  render  it  so  j  American  Journal  of  the  Medical  Sciences,  April,  1884. 
valuable    to    the   medical    jurist.      The    copious  | 

TAYLOB,  ALFBED  S,,  M.  D., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  m  Gruy^s  Hospital,  London. 

A  Manual  of  Medical  Jurisprudence.  Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.  Edited  by  .John  J.  Eeese,  M.  D.,  Professor 
of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennisylvania.  In  one 
large  octavo  volume  of  937  pages,  with  70  illustrations.  Cloth,  $5.00 ;  leather,  $6.00 ;  half 
Pussia,  raised  bands,  $6.50. 


The  American  editions  of  this  standard  manual 
have  for  a  long  time  laid  claim  to  the  attention  of 
the  profession  in  this  country;  and  the  eighth 
comes  before  us  as  embodying  the  latest  thoughts 
and  emendations  of  Dr.  Taylor  upon  the  subject 
to  which  he  devoted  his  life  with  an  assiduity  and 
success  which  made  him  facile  princeps  among 
English  writers  on  medical  jurisprudence.  Both 
the. author  and  the  book  have  made  a  mark  too 
deep  to  be  atfected  by  criticism,  whether  it  be 
censure  or  praise.  In  this  case,  however,  we  should 


only  have  to  seek  for  laudatory  terms. — American 
Journal  of  the  Medical  Sciences,  Jan.  1881. 

This  celebrated  work  has  been  the  standard  au- 
thority in  its  department  for  thirty-seven  years, 
both  in  England  and  America,  in  both  the  profes- 
sions which  it  concerns,  and  it  is  improbable  that 
it  will  be  superseded  in  many  years.  The  work  is 
simpl3nndispensable  to  every  physician,  and  nearly 
so  to  every  liberally-educated  lawyer,  and  we 
heartily  commend  the  present  edition  to  both  pro- 
fessions.— Albany  Law  Journal,  March  26, 1881. 


By  the  Same  Author. 

The  Principles  and  Practice  of  Medical  Jiu-isprudence.  Third  edition. 
In  two  handsome  octavo  volumes,  containing  1416  pages,  with  188  illustrations,  doth,  $10 ; 
leather,  $12.     Jtbst  ready. 

For  years  Dr.  Taylor  was  the  highest  authority  |  matters  connected  with  the  subject,"  should  be 
in  England  upon  the  subject  to  which  he  gave  j  brought  up  to  the  present  day  and  continued  in 
especial  attention.  His  experience  was  vast,  his  j  its  authoritative  position.  To  accomplish  this  re- 
judgment  excellent,  and  his  skill  beyond  cavil.  It  i  suit  Dr.  Stevenson  has  subjected  it  to  most  careful 
is  therefore  well  that  the  work  of  one  who,  as  Dr.  i  editing,  bringing  it  well  up  to  the  times. — Ameri- 
Stevenson  says,  had  an  "enormous  grasp  of  all  i  can  Journal  (^  the  3Iedical  Sciences,  Jan.  188i. 


By  the  Same  Author. 

Poisons  in  Relation  to  Medical  Jurisprudence  and  Medicine.  Third 
American,  from  the  third  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.     Cloth,  $5.50 ;  leather,  $6.50. 


JPEFFEB,  AUGUSTUS  J,,  M.  S,,  M.  B.,  F.  M.  C.  S., 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 

Forensic  Medicine.  In  one  pocket-size  12mo.  volume.  Preparing.  See  Students' 
Seriea  of  Manuals,  page  4. 

LEA.SENBYC. 

Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,  The  Ordeal  and  Torture.  Third  revised  and  enlarged  editioii.  In  one 
handsome  royal  12rao.  volume  of  552  pages.     Cloth,  $2.50. 

should  not  be  most  carefully  studied ;  and  however 
well  ver.'-ed  the  reader  may  be  in  the  science  of 
jurisprudence,  he  will  find  much  in  Mr.  Lea's  vol- 
ume of  which  he  was  previously  ignorant.  The 
book  is  a  valuable  addition  to  the  literature  of  so- 
cial science. —  Westminster  Iteview,  Jan.  1880. 


Thi.s  valuable  work  is  in  reality  a  history  of  civ- 
ilization as  interpreted  by  the  progress  of  jurispru- 
dence. .  .  Id  ".Superstition  and  Force"  we  have  a 
philosophic  survey  of  the  long  period  intervening 
between  prinjitive  barbarity  and  civilized  enlight- 
enment.   There  is  not  a  chapter  in  the  work  that 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 


efit of  Clergy— Excommunication 
octavo  volume  of  605  pages.     Clotli,  $2.50. 

The  author  is  pre-eminently  a  scholar.  He  takes 
up  every  tf>pic  allied  with  the  leading  theme,  and 
traces  it  out  U,  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  troiitrnent  that 
compel  admiration.  The  amount  of  information 
comprfsned  into  the  book  is  extraordinary.  In  no 
other  Hingle  volume  in  the  development  of  the 


New  edition.     In  one  very  handsome  royal 
Just  ready. 

I  primitive  church  traced  with  so  much  clearness, 
and  with  so  definite  a  perception  of  complex  or 
I  conflicting  sources.     The  fifty  pages  on  the  growth 
I  of  the  papacy,  for  instance,  are  admirable  for  con- 
ciseness and    freedom    from    prejudice. — Boston 
Traveller,  May  3, 1883. 


Allen's  Anatomy       .    . 

American  Journal  of  the  Medical  Sciences 

American  System  of  OynfecolOKy    ■ 

American  System  of  Practical  Medicine 

An  American  System  of  Dentistry 

*Ashhursfs  Surgery     .... 

Ash  well  on  Diseases  of  Women 

Attfield's  Chemistry      .... 

Ball  on  the  Rectum  and  Anus 

Barker's  Obstetrical  and  Clinical  Essays, 

Barlow's  Practice  of  Medicine 

Barnes'  Midwifery 

♦Barnes  on  Diseases  of  Women 

Barnes'  System  of  Obstetric  Medicine 

Bartholow  on  Electricity 

Basham  on  Renal  Diseases    . 

Bell's  Comparative  Physiology  and  Anatomy 

Bellamy's  Operative  Surgery 

Bellamy's  Surgical  Anatomy 

Blandford  on  Insanity  .  . 

Bloxam's  Chemistry 

*Bristowe's  Practice  of  Medicine    . 

Broadbent  on  the  Pulse 

Browne  on  the  Ophthalmoscope 

Browne  on  the  Throat 

Bruce's  Materia  Medica  and  Therapeutics 

Erunton"s  Materia  Medica  and  Therapeutics 

Bryant  on  the  Breast    .... 

*Bryant's  Practice  of  Surgery 

"'Bumstead  on  Venereal  Diseases    . 

'''Burnett  on  the  Ear       .... 

Butlin  on  the  Tongue    .... 

Carpenter  on  the  tJse  and  Abuse  of  Alcohol 

'''Carpenter's  Human  Physiology    . 

Carter  on  the  Eye  .... 

Century  of  American  Medicine 

Chambers  on  Diet  and  Regimen 

Charles'  Physiological  and  Pathological  Chem, 

Churchill  on  Puerperal  Fever 

Clarlie  and  Lockwood's  Dissectors'  Manual 

Classen's  Quantitative  Analysis 

Cleland's  Dissector 

Clouston  on  Insanity 

Clowes'  Practical  Chemistry 

Coats'  Pathology  .... 

Cohen  on  the  Throat     .... 

Coleman's  Dental  Surgery 

Condie  on  Diseases  of  Children 

Cornil  on  Syphilis  .... 

*Comil  and  Ranvier's  Pathological  Histology 

CuUerier's  Atlas  of  Venereal  Diseases 

Curnow's  Medical  Anatomy 

Dalton  on  the  Circulation 

'i'Dalton's  HumanPhysiology 

Davis'  Clinical  Lectures 

Draper's  Medical  Phj'sics 

Druitt's  Modern  Surgery 

Duncan  on  Dieeases  of  Women 

*Dunglison's  Medical  Dictionary    . 

Edes'  Materia  Medica  and  Therapeutics 

Edis  on  Diseases  of  Women    . 

Ellis'  Demonstrations  of  Anatomv 

Emmet's  Gynaecology  "  . 

*Er)chsen's  System  of  Surgery 

Esmarch's  Early  Aid  in  Injuries  and  Accid'ts 

Farquharson's  Therapeutics  and  Mat.  Med. 

Fenwick's  Medical  Diagnosis 

Finlayson's  Clinical  Diagnosis 

Flint  on  Auscultation  and  Percussion 

Flint  on  Phthisis  .... 

Elint  on  Physical  Exploration  of  the  Lungs 

Flint  on  RespiratoiT  Organs 

Flint  on  the  Heart         .  .  . 

■''Flint's  Clinical  Medicine 

Flint's  Essays       .  .  .  • 

*Flint's  Practice  of  Medicine 

Folsom's  Laws  of  U.  S.  on  Custody  of  Insane 

Foster's  Physiology'       .... 

*Fothergill''s  Handbook  of  Treatment     , 

Fownes'  Elementary  Chemistry 

Fox  on  Diseases  of  the  Skin  . 

Fraubland  and  Japp's  Inorganic  Chemistry 

Fuller  on  the  Lungs  and  Air  Passages     . 

Galloway's  Analysis     .... 

Gibney's  Orthopjedic  Surgery 

Gould's  Surgical  Diagnosis     . 

■"Gray's  Anatomy  ..... 

Greene's  Medical  Chemistry  . 

Green's  Pathologj'  and  Morbid  Anatomy 

Griffith's  Universal  Formulary 

Gross  on  Foreign  Bodies  in  Air-Passages 

Gross  on  Impotence  and  Sterility    . 

Gross  on  Urinarj-  Organs 

■"Gross' System  of  Surgery 

Habershon  on  the  Abdoinen 

■"Hamilton  on  Fractures  and  Dislocations 

Hamilton  on  Nervous  Diseases 

Hartshorne's  Anatomy  and  Phvsiology  . 

Hartshorne's  Conspectus  of  the  Med.  Sciences 

Hartshorne's  Essentials  of  Medicine 

Hermann's  Experimental  Pharmacology 

Hill  on  Syphilis  ..... 

Hillier's  Handbook  of  Skin  Diseases 

Hoblyn's  Medical  Dictionary 

Hodge  on  Women  .... 

Hodge's  Obstetrics        .... 

Hoffmann  and  Power's  Chemical  Analysis 

Holden's  Landmarks    .... 

Holland's  Medical  Notes  and  Reflections 

■"Holmes' System  of  Surgery 


6 
3 

27 
15 
24 
20 
28 
9 
4,21 
29 
18 
29 

29 
17 
24 

4,  7 

4,20 
6 
19 
9 
14 

4,16 
23 
18 
11 
11 

4,21 
21 
2.5 
24 

4,21 

8 

8 

23 

14 

18 

10 

28 

4,6 

10 

5 

19 

10 

13 

IS 

24 

30 

25 

13 

25 

4,  6 


28 
21 
21 
12 
16 
16 
18 
18 
18 
18 
18 
16 
16 
14 
19 

8 
16 

9 
26 

9 
18 

8 

20 

4,20 

5 
10 
13 
11 
18 


Horner's  Anatomy  and  Histology 

Hudson  on  Fever 

Hutchinson  on  Sj'philis 

Hyde  on  tlie  Diseases  of  the  Skin    . 

Jones  (C.  Handfield)  on  Nervous  Disorders 

Juler's  Ophthalmic  Science  and  Practice 

Keating  on  Infants 

King's  Manual  of  Obstetrics 

Klein's  Histology 

Landis  on  Labor  .... 

La  Roche  on  Pneumonia,  Malaria,  etc.     . 

La  Roche  on  Yellow  Fever    . 

Laurence  and  Moon's  Ophthalmic  Surgery 

Lawson  on  the  Eye,  Orbit  and  Eyelid 

Lea's  Studies  in  Church  History 

Lea's  Superstition  and  Force 

Lee  on  Syphilis 

Lehmann  s  Chemical  Physiology    . 

■"Leishman's  Midwifery 

Lucas  on  Diseases  of  the  Urethra   . 

Ludlow's  Manual  of  Examinations 

Lyons  on  Fever   ..... 

Maisch's  Organic  Materia  Medica  . 

Marsh  on  the  Joints 

May  on  Diseases  of  Women   . 

Medical  News 

Medical  News  Visiting  List  . 

Medical  News  Phj'sicians'  Ledger  . 

Meigs  on  Childbed  Fever 

Miller's  Practice  of  Surgery   . 

Miller's  Principles  of  Surgery 

Mitchell's  Nervous  Diseases  of  Women   . 

Morris  on  Diseases  of  the  Kidney 

MoiTis  on  Skin  Diseases 

Neill  and  Smith's  Compendium  of  Med.  Sci. 

Nettleship  on  Diseases  of  the  Eye  . 

Norris  and  Oliver  on  the  Ej-e 

Owen  op  Diseases  of  Children 

■"Parrish's  Practical  Pharmacy 

Pariy  on  Extra-Uterine  Pregnancy 

Parvin's  Midwifery         .... 

Pavy  on  Digestion  and  its  Disorders 

Pepper's  System  of  Medicine 

Pepper's  Forensic  Medicine   . 

Pepper's  Surgical  Pathology 

Pick  on  Fractures  and  Dislocations 

Pirrie's  System  of  Surgery    . 

Playfair  on  Nerve  Prostration  and  Hysteria 

■■■■Playfair's  Midwifery  . 

Politzer  on  the  Ear  and  its  Diseases 

Power's  Human  Phvsiologv  . 

Purdy  on  Bright's  Disease  and  Allied  Afiections 

Ralfe's  Clinical  Chemistry 

Ramsbotham  on  Parturition 

Remsen's  Theoretical  Chemistry    . 

■"Reynolds'  System  of  Medicine 

Richardson's  Preventive  Medicine 

Roberts  on  Urinary  Diseases 

Roberts'  C'ompend  of  Anatomy 

Roberts'  Principles  and  Practice  of  Surgery 

Robertson's  Physiological  Physics 

Ross  on  Nervous  Diseases 

Sargent's  Minor  and  Military  Surgery     . 

Savage  on  Insanity,  including  Hysteria  . 

Schaier's  Essentials  of  Histology, 

Schreiber  on  Massage   . 

Seller  on  the  Throat,  Nose  and  Naso-Pharynx 

Series  of  Clinical  Manuals 

Simon's  Manual  of  Chemistry 

Skey's  Operative  Surgery 

Slade  on  Diphtheria 

Smith  (Edward)  on  Consumption 

■"Smith  (J.  Lewis)  on  Children 

StlUe  on  Cholera 

*Still6  &  Maisch's  National  Dispensatory 

■"Stillg's  Therapeutics  and  Materia  Medica 

Stimson  on  Fractures   .... 

Stimson's  Operative  Surgery 

Stokes  on  Fever  ..... 

Students' Series  of  Manuals  . 

Sturges'  Clinical  Medicine 

Tanner  on  Signs  and  Diseases  of  Pi'egnancy 

Tanner's  Manual  of  Clinical  Medicine 

Taylor  on  Poisons  .... 

■"Taylor's  Medical  Jurisprudence    . 

Taylor's  Priu.  and  Prac.  of  Med.  Jurisprudence 

■'■Thomas  on  Diseases  of  Women 

Thompson  on  Stricture 

Thompson  on  Urinary  Organs 

Tidy's  Legal  Medicine .... 

Todd  on  Acute  Diseases 

Treves'  Manual  of  Surgery    . 

Treves'  Surgical  Applied  Anatomy 

Ti'eves  on  Intestinal  Obstruction    . 

Tuke  on  the  Influence  of  Mind  on  the  Body 

Visiting  List,  The  Medical  News    . 

Walshe  on  the  Heart    .  .  .        '. 

Watson's  Practice  of  Physic  . 

■"Wells  on  the  Eye         .... 

West  on  Diseases  of  Childhood 

West  on  Diseases  of  Women 

West  on  Nervous  Disorders  in  Childhood 

Williams  on  Consumption 

Wilson's  Handbook  of  Cutaneous  Medicine 

Wilson's  Human  Anatomy   . 

Winckel  on  Pathol,  and  Treatment  of  Childbed 

Wohler's  Organic  Chemistry 

Woodhead's  Pi-actical  Pathology    . 

Year-Books  ot  Treatment  for  1884  and  1886 


Books  marked  '*  are  also  bound  in  half  Enssia. 


LEA    BROTHERS    &    CO.,    Philartelpliia. 


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